Skip to main content

Full text of "Irish journal of medical science"

See other formats 


Irish  journal  of  medical 

Biological 

o 

&  Medical 

science 

'  5.  .,  y  >."■ 

Serials 

il-   ' 

ST< 

J>RAGC 

■ 

I  ^8fc^  ^^ 


^Sacri 


^0, 


RAG 

iBBLm  JOUMAL 


ff^ 


MEDICAL   SCIENCE: 

[Late  DvBUN  QuARTKHtr  Joursai.  up  Msdical  Scibnck.] 


CONTAINING 


KIGINAL     COMMUNICATIONS, 

REVIEWS,  ABSTRACTS,  AND  REPORTS, 


i 


1 


IN 


1 


tWxm,  Sxtrgery,  anir  Collatti^^l  .§mtiice^i  /] 


l^jf    Edit6d  by  J.  W.  MOORE,  B.A.,  M.D.,  Univ.  DubL  ;  F.R.C.P.I. ;  etc. 

7 


THIRD  SERIES. 
No.  CCXLVll. 


JUL  K, 
1892. 


A,o^ 


AO 


^-^ 


DUBLIN  :    FANNIN  »&  CO.,  GRAKTON-STREKT, 
whom,  Communications  for  the  Editor  and  Books  for  Review  are  to  be  addressed, 
\\lj\jl  LONDON  :  LONGMANS  &  CO.  ;  SIMPKIN,  MARSHALL  &  CO. 

''^"  EDINBURGH  :  JAMES  THIN. 

AtiSVAL  iUBSCRlPTiOK,  £1, —  SINGLK  SVMIIKH,  2a 


N  the  treatment  of  AncBmia^  Epilepsy ^  Hysteria^ 
Neuralgia^  and  Nervous  Exhaustion,  Fletchers' 
Hydrobromates  are  especially  valuable. 

In  cases  where  even  small  doses  of  Quinine 
produce  severe  head  symptoms,  the  Hydrobromates  may 
be  freely  administered  without  the  slightest  disagreeable 
result. 

Patients  intolerant  of   Iron  in  every  other  form  c^n 
readily  assimilate  the   Hydrobromate  -     j    r 

combination. 

rDHESE 

P.epa.Snsca„ 

now    be    presented   in 

07'iginal    bottles,     conimning 

ounces,     each   provided 

th  glass   measure  and  stirring-rod. 

Physicians  wishing  to  order  Fletchers' 
Hydrobromates  are  respectfully  invited  to  prescribe 
them  in  this  form,  as  various  imitations  of  the  genuine 
compounds  are  frequently  substituted. 

Fletcher,  Fletcher  &  Stevenson, 

Manufacturing  Chemists.  Holloway,  London,  N. 


ADVERTISING   SHEET,  N^-  247. 


NOW  READY,  with  Coloured  Plates  and  numerous  Charts.     560  pp.     Price  I5s. 


OF   THB 

ERUPTIVE  AND  CONTINUED  FEVERS. 

BY 

JOHN  WILU AM  MOORE,  B.A.,  M.D.,  M.CH.,  Univ.DUBL; 

FBLLOW   AND    REQISTRAR   OP   THB   ROYAL   OOLLEGB   OF    PHYSICIANS   OF  IBBLAND  • 

PHYSICIAN    TO   THB    MEATH    HOSPITAL,    DUBLIN  ; 

JOINT   PROFESSOR    OF    PRACTICE    OF    MEDICINE    IN    THE   SCHOOLS    OF   SDBGBBT   OF    THE 

ROYAL    COLLEGE   OF    SURGEONS    IN    IRELAND  ; 

CONSULTING    PHYSICIAN    TO    CORK-STREET   FEVER    HOSPITAL,    DUBLIN,    AND    TO    THE 

WHITWOETH    HOSPITAL,    DROMCONDRA  ; 
EX-8CH0LAR   AND   DIPLOMATE   IN    STATE    MEDICINE   OF   TRINITY   COLLEGE,    DUBLIN. 


OPINIONS  Of  THE  PRESS. 


"The  text-book  is  well  illustrated  with  charts  of  the  temperature  ranges  of  smallpox  and  of  the 
other  fevers,  eruptive  and  continued,  and,  with  three  exceptions,  they  have  been  reproduced  from 
charts  talten  from  the  author's  hospital  practice.      .  .      The  latest  and  soundest  information  is 

afforded  in  regard  to  the  eiiology  pathology,  clinical  history,  and  treatment  of  this  group  of  diseases. 
,  .  .  In  a  book  containing  so  much  and  such  a  variety  of  information  it  is  embarrassing  to  know 
what  to  select  for  notice,  and  we  need  scarcely  add  that  there  are  a  number  of  subjects  which  we 
should  have  gladly  touched  upon,  but  our  space  is  already  exhausted.  This  text-book  of  the  eruptive 
and  continued  fevers  is,  in  our  opinion,  a  learned  and  able  work.  A  reference  to  the  index  of  names 
will  show  the  large  number  of  authorities  which  its  author  has  consulted  and  quoted,  and  be  8ulhcient 
evid  nce  of  the  laborious  nature  of  the  undertaking.  The  work  is  clearly  written,  and  has  merits 
which  will  commend  it  to  the  profession." — The  Lancet. 

"  The  task  which  Dr.  Moore  set  himself  has  been  accomplished  with  great  success.  He  has  pro- 
duced a  work  which  will  not  only  serve  as  a  manual  on  fevers  to  students,  but  will  certainlj  be 
treasured  by  them  as  their  guide  and  counaellor  when  they  have  become  qualified  to  pructi8e."--i'ruc- 
titioner. 

'•  The  most  remarkable  'hing  about  the  book  is  its  absolute  freshness ;  everything  is  written  up  to 
the  very  last  moment.      .      .  We  can  confidently  recommend  the  Ijook,  not  so  much  as  a  philo- 

sophical study  of  fevers,  as  a  complete  compendium  and  guide  to  theii-  symptoms  and  treatment 
compiled  by  an  observant  physician  and  skilful  writer." — Edinburgh  Medical  Journal. 

"  What  Murchison  did  for  continued  fevers,  Moore  has  now  supplied  for  thoseof  an  eruptive  nature. 
,  .  .  No  monograph  dealing  with  ihis  subject,  as  fully  and  as  adequately  as  it  unquestionably  demands, 
has  hitherto  been  published.  .  .  .  The  work  is  thoroughly  well  got  up ;  free  use  has  been  made  of 
enlarged  type  for  important  words  and  for  sub-headings;  and  there  are  throughout  numerous  charts 
reproduced  from  tliosj  of  actual  cases." — Hospital  Gazette. 

"  A  very  careful  and  conscientious  piece  of  work,  which  contains  a  very  excellent  account  of  all 
that  modern  observation  and  research  has  added  to  the  already  well-worn  theme  of  the  history  and 
pathology  of  the  eruptive  and  continued  fevers."— ^irmmsr/mm  Medical  Revieie. 

•'  A  work  which  will  at  once  take  rank  as  one  of  the  best,  if  not  the  best,  work  upon  fevers  which 
has  yet  issued  from  the  English  press.  .  .  .  We  can  with  confidence  reooramend  our  renders  to 
procure  the  work,  a  study  of  which  will  more  than  repay  the  busy  practitioner  or  the  earnest  student 
It  would  be  a  serious  omission  were  we  to  omit  mention  of  the  excellent  style  in  which  the  work  is  got 
up.  Tlie  illustration.s,  the  temperature  charts,  the  printing,  and  the  paper,  are  of  the  very  best  quality 
and  reflect  the  highest  credit  upon  the  publishers."— i<rJ<uA  and  Foreign  Health  Resorts. 

"  A  valuable  work,  and  one  which  represents  a  vast  amount  of  labour  and  extended  clinical 
experience  with  this  claaa  of  diseases."— Cincinnati  Lanett  CItnie. 


Dublin  :  Fannin  &  Co.,  41  Grafton-street. 

London  :  BAiLLiaBB,  Tindall,  &  Cox.         Bristol :  John  Weight  &  Co. 

Edinburgh :  Jahbs  Thim. 


Duhlin   Tonrual  of  Medical  Science. 


CONDENSED    PRICE    LIST    OF 

THE  F.  A.  DAVIS  COMPANY'S  PUBLICATIONS, 

40  Berners-st.,  LOIVDOIV,  AV. 

Depot  for  Ireland :  FANNIN  &  CO.,  41  Grafton-street. 


Annual  of  the  Universal  Medical  Sciences.     Issue  of  1888.     5  vols. 

8vo.     Illustrated.     Cloth,  f.5  12s.  ;  Half-Russia,  £7.     Pp.  2,600. 

Annual  of  the  Universal  Medical  Sciences.   Issue  of  1889.   5  vols.     8vo. 

Illustrated.     Cloth,  £4  Ts. ;  Half- Russia,  £5  los.    Pp.  2,600. 

Annual  of  the  Universal  Medical  Sciences.   Issue  of  1890.  5  vols.     8vo. 

Illustrated.     Cloth,  M  7s. ;  Half-Russia,  £5  ISs.     Pp.  2,600. 

Annual  of  the  Universal  Medical  Sciences.    Issue  of  1891.    5  vols.  8vo. 

Illustrated.     Cloth,  £4  7s.  ;  Half-Russia,  £5  158. 
Bashore — Improved  Clinical  Charts.     Per  Tablet  of  50,  size,  8  by  12 

inches,  3s.  6d. 
Bashore — Bedside  Charts,  improved  by  A.  0.  Ward,  M.D. — 100  Charts 

(threefold)  iu  packet,  size,  3  by  5 J  inches,  4s.  ;  Single  Slips,  100  in  packet,  3s. ; 

Blank  Memorandum  Slips  (threefold),  2s.  6d.  per  100. 
Bowen — Materia  Medica,  Pharmacy,  and  Therapeutics.     12mo.     Cloth, 

88.  6d.     Pp.  370. 
Capp — The  Daughter  :  Her  Care  and  Instruction  in  Regard  to  Health. 

12mo.     Cloth,  5s.  6d. 
Cathell — Book  on  the  Physician  Himself.    Ninth  Edition.     8vo.    Cloth, 

lis.  6d.     Pp  289. 

Clevenger — Spinal  Concussion.    Illustrated.    8vo.    Cloth,  14s.    Pp.  359. 

Davis — Diseases  of  the  Heart,  Lungs,  and  Kidneys.  12mo.  In  pre- 
paration. 

Demarquay — Oxygen  and  Other  Gases  in  Medicine  and  Surgery. 
Translated  by  Samuel  S.  Wallian,  A.M.,  M.D.  Illustrated.  Svo.  Cloth, 
lis.  6d.     Pp.  316. 

Edinger — Twelve  Lectures  on  the  Structure  of  the  Central  Nervous 
System,  for  Physicians  and  Students.  Second  Edition.  Illustrated.  Trans- 
lated from  the  German  by  "Wilus  H.  Vittum,  M.D.,  and  Edited  by  C.  E. 
EiGGS,  M.D.     Svo.     Cloth,  10s.     Pp.  230. 

Eisenberg — Bacteriological  Diagnosis.  Translated  from  the  German, 
with  permission  of  the  author,  by  NoRVAL  H.  Pierce,  M.D.  Svo.  Cloth,  Ss.  6d. 
In  Press. 

Goodell — Lessons  in  Gynaecology.  Illustrated.  Svo.  Cloth,  22s.  6d. ; 
Sheep,  288,     Pp.  578. 

Guernsey — Plain  Talks  on  Avoided  Subjects.  16mo.  Cloth,  6s.  Pp.  126. 

Hare — Epilepsy:  Its  Pathology  and  Treatment.  12mo.  Cloth,  6s.  6d. 
Pp.  228. 

James — American  Resorts,  vrith  Notes  upon  their  Climate.  Svo.  Cloth, 
lis.  6d.     Pp.  285. 

Journal   of  Laryngology,    Rhinology,    and    Otology:   an   Analytical 

Record  of  Current  Literature  relating  to  the  Throat,  Nose,  and  Ear.     138.  (3 
Dullare)  per  annum,  post  free  ;  single  copies,  Is.  3d. 


AdvertiaenipiiU  coimected  with  Literature  and  the  Arf.<^.  3 

The  F.  A.  Davis  Company's  Publications — continued 

Keating  and  Edwards — Diseases  of    the   Heart  and   Circulation    in 

Children.     Illustrated.     8vo.     Cloth,  Ss.  6d.     Pp.  228. 
Keating — Record-Book  of  Medical  Examinations  for  Life  Insurance. 
16mo.     No.  1,  for  100  Examinations,  cloth,  38.  6d. ;  No.  2,  for  200  Examina- 
tions, 4s.  6d. 

Liebig  and  Rohe — The  Practical  Application  of  Electricity  in  Medicine 
and  Surf^ery.     Illustrated.     8vo.     Cloth,  lis.  6d.     Pp.  383. 

Manton — Childbed :  Its  Management :  Diseases  and  their  Treatment. 
In  preparation. 

Massey — Electricity   in   the    Diseases    of    Women,      Second   Edition. 

lUustrated.     12mo.     Cloth,  8s.  6d.     Pp.  240. 
Mears— Practical  Surgery.    Illustrated.  i2mo.    Cloth,  13s.  6d.    Pp.  794. 

Medical  Bulletin.  A  Monthly  Journal  of  Medicine  and  Surgery. 
Per  year,  5s. 

Medical  Bulletin  Visiting  List  or  Physicians'   Call-Record.     Upon 

an  Entirely  New  and  Convenient  Plan.     All  Leather,  4s.  6d. 
Michener — Hand-book  of  Eclampsia.     16mo.     Cloth,  4s.  6d.    Pp.68. 
Nissen — Swedish     Movement    and    Massage   Treatment.       Diustrated. 

12mo.     Cloth,  6s.     Pp.  128. 
Physicians'  All-Eequisite  Account-Book.     Quarto.     For  900  Accounts 

per  year,  28s.;  for  1800  Accounts  per  year,  42s. 
Physicians'  Interpreter.     In  four  languages.      Flexible  Leather.     6s. 

Pp.  206,     Size,  5  by  2|  inches,  6s. 

Price  and  Eagleton — Three   Charts   of  the   Nervo- Vascular   System. 

Per  set,  3s.  6d. 
Purdy — Diabetes :  Its  Causes,  Symptoms,  and  Treatment.   12mo.   Cloth, 

68.  6d.     Pp.  200. 
Ranney — Diseases  of  the  Nervous  System.     Illustrated.     8vo.     Cloth, 

32s. ;  Sheep,  37s.  6d.  ;  Half- Russia,  40s.     Pp.  780. 
Rohe — Text-book    of   Hygiene.      Second   Edition.      Illustrated.       Svo. 

Cloth,  14s.     Pp.  400. 
Sajous — On  Hay  Fever.     Illustrated.     Svo.     Cloth,  6s.     Pp.  103. 
Sajous — Diseases  of  the  Nose  and  Throat.      Illustrated.     Svo.     Cloth, 

22a  6d.  ;  Sheep.  288. ;  Half-Russia.  288.     Pp.  439. 
Sanne — Diphtheria,  Croup,  and  Tracheotomy.  Illustrated.    Svo.    Cloth, 

22s.  6d.  ;  Sheep,  28s.     Pp.  657. 
Satellite — A  Monthly  Review  of  the  Progress  of   Practical  Medicine 

throughout  the  World.     78.  fid.  per  annum,  post  free ;  single  copies,  6d. 
Senn — Principles  of  Surgery.     Illustrated.    Svo.    Cloth,  24s.  6d ;  Sheep, 

308.    Pp.  611. 
Shoemaker— The  Oleates.   Second  Edit.  12mo.    Cloth,  8s.  6d.  Pp.  298. 
Shoemaker  and  Aulde — Materia  Medica,  Pharmacology,  and  Therapeu- 
tics.    8vo.    Volume  I.     Cloth,  Hs.     Pp.  353. 
Smith,  R  Meade — Physiology  of  the  Domestic  Animals.     Illustrated. 

8vo.     Cloth,  288. ;  Sheep,  328.     Pp.  938. 
Stewart — Obstetric  Synopsis.  Illustrated.  12mo.  Cloth,  6s.  Pp.  202. 
Ultzman — Genito-Urinary    Neuroses.     Translated    by    Gardner    W. 

Allen,  M.D.     Illustrated.     12mo.     Cloth,  68.     Pp.  160. 
Witherstine — The   International   Pocket   Medical   Formulary.      16mo. 

Bound  in  Flexible  Leather,  with  Flap,  lis.  6d.     275  printed  pages  besides  extra 

blank  leaves. 
Young — Svnopsis  of   Human  Anatomy.      Illustrated.      12mo.     Cloth, 

Be.  6d.  'Pp.  390. 


Dublin  Journal  of  Medical  Science. 


The  F.  A.  Davis  Company's  Publications — continued. 

Capp,  William  M.,  M.D. — The  Daughter :  Her  Health,  Education,  and 
Wedlock.  Homely  Suggestions  for  Mothers  and  Daughters.  Pp.  144.  Price 
5s.  6d. 

Hare,  Hobart  Amory,  M.D.,  B.Sc. — Fever :  its  Pathology  and  Treat- 
ment by  Antipyretics.     12mo.     Cloth,  6e.  66.     Pp.  166. 

Mackenzie,  Sir  Morell — Twenty  Cases  Treated  by  Tuberculin.  Price 

Is.  nett. 

Senn,  N.,  M.D.,  Ph.D.,  Milwaukee,  Wise. — Principles  of  Surgery.  8vo. 

Over  100  Illustrations.     Cloth,  248.  6d. ;  all  leather,  30s.     Pp.  611. 
Shoemaker,  John  V.,  A.M.,  M.D.,  Philadelphia,  Pa. — Heredity,  Health, 

aud  Personal  Beauty.     In  one  royal  8vo  volume.     14s.     Pp.  4'22. 

Shoemaker.  John  V.,  A.M.,  M.D. — Materia  Medica,  Pharmacology,  and 

Therapeutics.     Vol.  H.     8vo.     Pp.  625.     198.,  in  Cloth. 
Sozinskey,    Thomas   S.,   M.D.,    Ph.D. — Medical   Symbolism.      12mOr 

Cloth,  6s.     Pp.  171. 
Wheeler,  H.  A.,  M.D. — Abstracts  of  Pharmacology.     5^  by  8  inches. 

Pp.  180.     Cloth,  88.  6d. 


OTTJST  :ftjbxjIss:e3D. 

Boenning,  H.  C,  M.D. — A  Treatise  on  Practical  Anatomy.     Illustrated. 

8vo.     Pp.481.     Cloth,  148. 
Bm"et. — Syphilis  :  To-Day  and  in  Antiquity.     To  be  completed  in  three 

1 2mo  volumes.     Volume  I.  Syphilis  in  Antiquity.     Pp.  226.    Cloth,  68.  6d. 
Coltman,    R.,    Jr.,  M.D. — The  Chinese  :    their   Present   and  Future ; 

Medical,  Political,  and  Social.     8vo.     Pp.  250.     Cloth,  10s. 
Davis,  N.  S.,  Jr. — Consumption  :  How  to  Prevent  it,  and  how  to  Live 

with  it.     12mo.     Pp.141.     Cloth,  4s. 
Huidekoper,  B.  S.,  M.D. — The  Age  of   the  Domestic  Animals.     8vo. 

200  Engravings.     Pp.  217.     Cloth,  lOs. 
Nissen,    Hartvig. — A  B   C  of    the    Swedish    System    of    Educational 

Gymnastics.     A  Practical  Handbook  for  School  Teachers  and  the  Home.  lUus- 

trated.     12mo.     Pp.  107.     Cloth,  4s. 
Remondino,  P.  C,  M.D. — Circumcision:  its  Hi.story,  Modes  of  Opera- 
tion. &c.     12mo.     Pp  346.     Cloth,  6s.  6d.  ;  paper,  Ss. 
B^mondino,  P.  C,  M.D. — Southern  California.     12mo.     Cloth,  6s.  6d, 
Kobe,  George  H.,  M.D.,  and  Lord,  M.D. — Practical  Manual  of  "  Skin 

Diseases."     12mo.     Cloth,  6s.  6d. 

Any  hooks  on  Medical  or  Scientific  Subjects  published  in  Great  Britain  or  the  United 
States  may  be  had  of  us  or  ordered  through  us. 


THE    IDEAL    VISITING    LIST. 

Only  OWE  Entry  of  Names  required  for  each  Month.     3s.  6d.  nett.     All  feather. 

The  PUREST  ANIMAL  LYMPH,  cultivated  from  CALF  to  CALF, 
under  supervision  of  the  Imperial  HEALTH  OFFICE,  at  the  Insti- 
tute of  Dr.  PISSIN,  in  Berlin. 

This  is  the  BEST  and  LEAST  EXPENSIVE  of  Vaccines  offered 
in  England.  [ASK  FOR  PRICE  LIST. 


F AN^N^IN^  &  CO.,  4X  GBAPTON-ST.,  DUBLIN. 


A dvei'ti<i€ments  connected  with  Literature  and  the  Arts, 


TENTH  YEAR,  8vo,  cloth,  about  800 pages.     Price  7s,  6d, 


THE  MEDICAL  ANNUAL 


Illastraled  wilh  COLOURED  PLATES  and  in  Black  and  White. 


Yearly  Circulation  exceeds  X0,000  Copies. 

A  CoMPLETB  Work  of  Repeebnoe  for  Mbdical  Fbaotitionebb,  and 

DICTIONARY  of  NEW  TREATMENT  in  MEDICINE,  SURGERY,  &  OBSTETRICS, 

With  many  orginal  articlee  by  distinguished  Specialists. 


SYNOPSIS  OF  CONTENTS. 


Jibdoxninal  Surgery- 

A.  Mato  Robsow,  F.RC.8. 
SacteriOlOgn^  (with  coloured  plates). 
M.  Aemand  Rdffek,  M.A-,  iLD. 

Bladder  and  Uretbra  (with  coloured 

plates).     E.  HrTRRT  Fenwick,  F.R.C.S. 

Cancer,    w.  h.  Elam,  f.r.c.s. 
Cbildren,  Diseases  of. 

Henrt  UwtGHT  Chapin,  JID.,  New 
York. 

dictionary  of  New  Remedies. 

Kdited  bv  Pkrcy  Wilde,  M.U. 

Digestive  Organs,  Disease  of 

Prof.  DujAEi'iN  Beauvtz,  M.D.,  Paris. 
£ar.  Diseases  of 

J.  DnNDAS  Grant.  M.A.,M.D.,F.R.C.S. 
£ye.  Diseases  of^ 

W.  Lang,  F  R.C.S. 

Heart,  Diseases  of. 

James  K.  Leaming,  M.D.,  New  Yorlc. 

Frank  \V.  Jackson.  M.D.,  New  York. 
Kidney,  Diseases  of. 

RoBT.  Saundby,  M.l).,  F  R.C.P. 
Ijungs,  Diseases  of. 

F.  DE  Uavillamh  Hall,  M.D.,F.R.aP. 
Medicine,  GheneraL 

F.  J.  Wethered,  M.D.Lond.,  M.R.C.P. 
P.  Watbun  Williams,  M.D.Lond. 

Kervous  System,  Diseases  oC. 

G.  M.  Hammond,  A.M.,  M.D.,  New  York. 


Nose,  Diseases  Of  (with  coloured  plate). 

Greviile  Macdonald,  M.D. 
Obstetrics. 

A.  H.  N.  L-EWEas,  M.D.Lond.,  M.R.C.P. 
Orthopaedics. 

John  Ridlon,  M.D.,  New  York. 

RoBT  Jones,  F.R.aS.E. 
Pbtbisis. 

R.  Shinglbtok  Smith,  M.D.L«nd.,  KSe^ 
F.R.C.P. 
Rectnm,  Surgery  of. 

H.  W.  Allingham,  F.R.CS. 
Sfcin,  Diseases  of. 

T.  Coi.coTT  Fox,  B.A.,  JLB.,  M.R.C.P, 
Surgery,  General  and  Brain. 

K.  S.  Eve.  K  R.C.S. 

Spinal  Surgery. 

W.  J    Thorblrn,  M.D.,  F,R.aS.,  B.Se. 
Synopsis  for  1890-91. 

Graham   Wills.  M.D." 

Tbroat,  Diseases  o£ 

p.  Watson  Williams,  M.D.,  Lond. 
Venereal  Diseases. 

Jon.  Hi'TOHiNsoN,  Junr.,  F.E.CJS. 
^Voraen,  Diseases  oL 

R.Milne  McrIvAT^  M.A.,  M.B.,  F.R.CP. 
Sanitation. 

Jos.  PRiE.STLSr.  B.A,,  M.D.,  D.P.H. 
PhOtOgrapby   (illustrated  by  Collotype 

Figs.).     ANUKBW  Pbin«)lb,  Esq. 


JVew  Inventions  and  Improvementt  in  Pharmacy,  *fcc.,  d:e. 

The  large  circulation,  which  exceeds  that  of  any  Annual  Medical  Work,  is  the 
best  proof  of  Its  Extreme  Value  to  ev«ry  practitioner  who  desirefi  to  keep  abreast 
of  the  times. 


BRISTOL:  JOHN  WRIGHT  &  CO.,  STONE  BRIDGE. 


Dxihlin  Journal  of  Medical  Science. 


Just  Published.     Price  Is. 


ACUTE  DOUBLE   PNEUMONIA 

SUCCESSFULLY   TREATED    BY 

BLEEDING  AND  INHALATION  OF  OXYGEN. 

By  GEORGE   FOY,    F.R.C.S.I. ; 

SURGEON   TO   THE    WHITWORTH    HOSPITAL,    DRUMCONDRA. 


Dublin  :  FANNLN  &  CO.,  41  Gkafton-stbeet. 


NOW  READY.     Price  2s.  6d.  nett. 

THE  HYDERABAD  CHLOROFORM  COMMISSION : 

A  REVIEW, 

By  GEORGE  FOY,  F.R. C.S.I.  ; 

SURGEON    TO   THE    WHITWORTH    HOSPITAL,    DRUMCONDRA. 


Dublin  :  Fannin  &  Co.,  41  Grafton- street. 


Just  Published,   Third  Edition,  price  \s.  6d.  nett. 

FOB 

THE    DIAGNOSIS  AND  TREATMENT 

OP 
BY 

JOHN    K.     BARTON,     M.  D.,    F.R.C.S.I., 

Senior  Surgeon  to  the  Adelaide  Hospital ;  Past  President  of  the  Royal  College  of 

Surgeons  in  Ireland  ;  Consulting-  Surgeon  to  the  Cripples'  Home,  Bray  ; 

Late  Lecturer  in  Surgery,  Carmichael  College,  &c. ; 

Author  of  "The  Pathology  and  Treatment  of  Syphilis,"  &c. 


DubKn  :   Fannin  &  Co.,  41  Grafton-street. 
London :  Baillieke,  Tindall,  &  Cox,  King  William-street 
i         Edinburgh :  E.  Thin,  South  Bridge. 

NOW  READY,  med.  8vo,  cloth,  556  pp.     With  numerous  Illustrations.     Price  14*. 

or   THE 

ROYAL  ACADEMY  OF  MEDICINE 

IN     IRELAND. 

VOL.    IX.— 1891. 

Edited  by  WILLIAM  THOMSON,  M.A.,  F.R.C.S., 

General  Secretaby; 
Surgeon  t«  the  Richmond  Hospital,  Dublin. 


Dublin:  FANNIN  &  CO.,  41  Geafton-street. 
London:  BAILLIERE,  TINDALL.  &  COX,  20  King  William  street,  Strand. 
Bristol:  JOHN  WRIGHT  &  CO.,  vStone  Bridge. 
EWNBUBOH  :  JAMES  THIN,  55  South  Bridge. 


Advertisements  connected  with  Literature  and  the  Arts.         7 

Fannin  &  Co.'s  Announcements. 

Just  published,  medium  8vo,  36i  pages,  price  9s.,  Illustrated. 

A  Handbook  of  Hospital  Practice 

and  PHYSICAL  DIAGNOSIS.  By  Christopher  J.  Nixon,  M.B., 
LL.D.,  Univ.  Uubl.  ;  M.D.  {Honoris  Causa),  R.U.I.  ;  Senior  Physician,  Mater 
Misericordiffi  Hospital ;  Professor  of  the  Theory  and  Practice  of  Medicine, 
Catholic  University  ;  Member  of  the  Senate  of  the  Royal  University  ;  Felh.w, 
Censor,  and  Examiner  in  Medicine,  King  and  Queen's  College  of  Physicians  • 
Examiner  in  Medicine,  Conjoint  Examination  of  the  Colleges  of  Physicians  and 
Surgeons  in  Ireland. 

Now  ready,  medium  ^vo,  180  pp.,  price  3s.  6rf. 

Anaesthetics,  Ancient  &  Modern; 

their  Physiological  Action,  Therapeutic  Use,  and  Mode  of  Administration  ; 
together  with  an  Historical  R(^.sum^  of  the  Introduction  of  Modern  Anaesthetics  ; 
and  also  an  account  of  the  more  celebrated  Anaesthetics  in  Use  from  the  earliest 
time  to  the  discovery  of  Nitrous  Oxide.     By  George  Fot,  F.R.C.S. 

Just  published,  price  Is.  net. 

Address  on  Bacteriology,  delivered  at 

the  Mater  Misericordise  Hospital,  May  23,  1890.  By  Edmond  J.  M'Weeney, 
M.A.,  M.B.,  M.Ch.,  M.A.O.,  &c.  Together  with  a  Report  of  the  Proceedings 
on  the  occasion  of  the  Inauguration  of  the  Bacteriological  Laboratory  at  the 
above  Tustitution. 

Just  published,  medium  8vo,  oblong,  price  2s.  net. 

Short  Analytical  Tables.  Arranged  by 

Edwin  Lapper,  Member  of  the  King  and  Queen's  College  of  Physicians  in 
Ireland  ;  Fellow  of  the  Institute  of  Chemistry  of  Great  Britain  ;  Member  of  the 
Society  of  Analysts ;  Lecturer  on  Chemistry  ;  Professor  of  Chemistry,  Royal 
College  of  Surgeons,  Ireland. 

Crown  8vo,  with  75  Engravings,  328  pages,  reduced  to  4s-  6d.,  or  with  Coloured 
Engravings,  6s.  6d. 

Anatomy  of  the  Arteries,    Descriptive 

AND  SURGICAL  ;  with  the  Descriptive  Anatomy  of  the  Heart.  By  J. 
H.  Power,  M.D.,  Fellow  and  formerly  Professor  of  Surgery,  R.C.S.I.  With 
Illustrations  from  Drawings  by  B.  W.  Richardson,  l<ellow  and  Examiner, 
R.C.S.I.  Edited  by  Wm.  Thomson,  M.D.,  Fellow  and  Examiner,  R.C.S.I.  ; 
Examiner  in  Surgery,  Queen's  University. 

Medium  8vo,  with  Index,  316  pages,  price  7s. 

The  Pathology  and  Treatment  of 

SYPHILIS,  CHANCROID  ULCERS,  and  their  Comidications. 
By  John  K.  Barton,  M.D.  (Dub.),  F.R.C.S.I.  ;  Surgeon  to  the  Adelaide 
Hospital ;  Lecturer  on  Surgery,  Ledwich  School  of  Medicine  ;  Visiting  Surgeon, 
Convalescent  Home,  StiUorgan  ;  Late  University  Anatomist,  University  Medical 
School;  Pathological  Society's  Gold  Medalist,  1852,  &c. 


Dublin  :  Fannin  &  Co.,  41  Graiton-street. 

London  :  Bailli^rb,  Tindall,  &  Cox  ;  J.  &  A.  Churchill  ;  Longmans,  Grbbn,  &  Co. 

Edinburgh:  James  Thin.  Bristol  :  J.  VVriuht  &  Co. 


Dublin  Journal  of  Medical  Science. 


NDIAN  MEDICAL  SERVICE 


India  Officb, 

nth  May,  1892. 

FOB 

Fourteen     Appointments 

TO 

Her  Majesty's  Indian  Medical  Service 

WILL   BE    HELD 

In  LONDON  on  the  8th  AUGUST,  1892, 

AND  FOLLOWING  DAYS. 


Copies  of  the  Regulations  for  the  Examination,  with  information 
regarding  the  Pay  and  Retiring  Allowances,  &c.,  of  Indian  Medical 
Officers,  may  be  obtained  from  the  Military  Secretary,  India  Office, 
London,  S.W.,  to  whom  the  necessary  certificates  must  be  sent,  so  as  to 
reach  him  not  later  than  Monday,  25th  July,  1892. 

0.  E.  NEWMARCH,  Major-Genebal, 

Military  Seci'etary. 

Abmt  Medical  Depabtmenp, 
Wab  Office, 

\2th  May,  1892, 

AN    EXAMINATION    OF    CANDIDATES 

roB 

TEN    COMMISSIONS 

IN 

The  Medical  Staff  of  Her  Majesty's  Army, 

WILL  BB  HELD  AT 

THE  UNIVERSITr  OF  LONDON.  BUELINGTON  GAKDENS,  W. 

(By  permission  of  the  Senate), 
On  the  8th  of  AUGUST  next,  and  following  days. 


Application  for  Admission  to  the  Examination  should  be  made  in  writing 
without  delay,  to  the  Director- General,  Army  Medical  Department,  War  Ofl5ce> 
London,  S.W. 

(Signed),        W.  A.  MACKINNON,  Director-General 


TAAFFE  &  COLDWELL'S 

CELEBRATED   PERFECT-FITTING 

SHIRT8. 

Best  Value  in  Ireland,  for  Ready  Mor\ey  otily. 

Our  Shirts  are  admitted  by  all  who  have 
worn  them  to  be  the  most  perfect  fitting  yet 
introduced,  giving  great  ease  and  comfort  to 
the  wearer,  without  creasing  or  wrinkling  in 
the  least. 

Every  Order  being  executed  on  the  premises,  under 
our  own  personal  supervision,  we  guarantee  in  every 
case  an  accurate  fit. 

As  we  sell  only  for  Ready  Money,  our  prices  will  be  found  fully 
15  per  cent,  lower  than  those  usually  charged  by  credit 
houses. 

White  Shirts,  Pure  Irish  Linen  fronts,  bands,  and  cuffs    ...  ...        3/6,  4/6 

„  „  „  (extra  fine)    5/6,  6/6,  7/6 

Evening  Shirts,  extra  wide  fronts  ...  ..,  ...  4/6,  6/6,  8/6 

Coloured  Shirts,  best  French  printed  Canibric      .«  ...  ...  ...    5/- 

,,  best  Oxford  Cashmere  cotton     ...  ...  ...  ...  5/6 

Flannel  Shirts,  thoroughly  shitrak  before  making  up  ...  6/6,  8/6,  10/6 

Calcutta  Flannel  Shirts,  special  light  make  for  Summer  wear  ...        6/6,  8/6 

Old  Shirts  refitted  with  new  linen  fronts,  bands,  and  cuffs...  ...         2/3,  2/9 

A  Sample  ShiPt  of  any  of  the  above  sent  post  free  to  any  address  in  the  United 
Kingdon>,  on  receipt  of  remittance  (foreign  postage  extra).  State  size  of  collar, 
height,  and  chest  measure.     Money  returned  if  not  approved  ©f. 

GENTLEMEN'S  NATURAL  UNDYED  WOOL 

SANITARY  UNDERCLOTHING. 

Free  from  all  irritating  or  injurious  dyes,  and  retaining  all  the 
Natural  Warmth  and  Softness  of  the  wool.  In  Summer  and 
Winter  weights  at  the  following  prices : — 

Under  Vests            ..,  ...  •-  .••           2/11,  4/6,  6/6,  8,6 

Pants     ...               ...  .„  ...  ...             3/6,  5/6,  716,  9/6 

Socks     ...               ...  ...  ...  1/-.  1,6,  1/11,  2  6 

THE  BEST  VALUE  IN     IRELAND. 

TAAFFE  &  OOLDWELL, 

SI     GRAFTON    STREET.    DUBLIN. 


^irst'i§lass  tailoring  at  §eady  (Money  i§rices. 


TAAFFE  &  COLDWELL, 

Invite  Inspection  of  their  New  Stock  of  COATINQiS, 
SUITINGS,  and  TROUSERINGS,  which  have  been 
Purchased  for  Cash  from  the  most  eminent  manufacn 
turers, 

SPECIALITIES- 

Best  Materials,  Good  Style,  Perfect  Fit,  First-Class  Workmanship, 
and  25  per  cent,  under  credit  houses, 

Angola  or  Cheviot  Trousers  ...  ...  13/-,  16/6,  19/6 

Tweed  or  Serge  Suits         ..  55/-,  63/-,  70/- 

lilack  Morning  Coat  and  Vest  ...  ...  ...          55/-,  70/- 

Dress  Coat  and  Vest  ...  ...  ...  ...         55/-,  70/- 

Dress  Trousers  ...  ...  15/6,  21/-,   25/- 

Lawn  Tennis  &  Cycling  Suits, 

SHIRTS,   TIES,    HOSE,   CAPS,   &e. 

The  LARGEST  STOCK  and   BEST  VARIETY  in   IRELAND  to  select  from. 

C^  SPEGIAUTE-'H.YGIENIC  CYCLING  SUITS, 

All  linings   guaranteed  Pure  Wool,  thus  avoiding  any  danger 
arising  from  chill. 

All  Goods  sold  at  lowest  possible  prices 
for  READY   MONEY   ONLY. 


TAAFFE  &  COLDWELL. 

81   GRAFTON   STREET,    DUBLIN. 

Sole  Agents  in  Dublin  for  the  Cellular  Clothing  Company 


Bliscedancous  :S,t)bertrscment5, 


THE    NATURAL    MINERAL    WATERS    OF 
STATE     k  ^    I    ^J  ^    M  SPRINGS. 

«  C  E  L  E  S  T  I N  S ." 

For  Diseases  of  the  Kidneys,  Gravel,  Gout,  Rheumatism,  Diabetes,  &c. 

"GRANDE -GRILLE." 

For  Diseases  of  the  Liver,  and  Biliary  Organs,  &c. 

«  H  6  P I  T  A  L ."  «  H  A  U  T  E  R  I Y  E  ." 

For  Stomach  Complaints.  An  Excellent  TABLE  WATER. 

SAMPLES  and  PAMPHLET  FREE  to  MEMBERS  of  the  MEDICAL 
PROFESSION  ON  APPLICATION. 


SOLE    AGENTS— 

INGRAM  &  ROYLE,  52  Farringdon  Street,  LONDON,  E.C., 

and  19  South  John-street,  Liverpool. 

DVAN  ABBOTT'S  GLUTEN   BREAD. 
lABETES.  SOYA  BREAD,  RUSKS,  BISCUITS. 

DAnd  all  suitable  Foods  for  Diabetic 
T^gg^'pp'g  Patients,  Sweetened  with  Saccharin 

or  Plain. 

DVAN  ABBOTT'S 
ELICATE  HYPOPHOSPHITE 

CHILDREN.        OF  LIME  BISCUITS. 

CYAN  ABBOTT'S 
ONSTIPATION.     BRAN  BISCUITS. 

Van  Abbott's  Dietary  Tables,  Menu,  Cooking  Receipts,  and  Price 
List  post  free  from 

C3-.  "VJLisr  j^BBOTT  &  soisrs. 

Diabetic,  It^ialid,  and  Infant  Dietetic  Depot, 

6  Duke-Btreet,  Mansions,  Grosvenor- square,  W.    Es-tablished  1859. 

Samples  Free  to  the  Profession. 

MEDICAL   PLATES. 


MEDICAL  PLATES  and   ILLUSTEATIONS 

EXECUTED  IN  VARIOUS  COLOURS  IN  THE  BEST  STYLE  BY 

JOHN  FALCONER, 

53     UPPER     SACK  VlLLE-a  TRKE  T.     DUBLIN- 


Founded  1805.    The  Oldest  Scottish  Insurance  Institutioii 

Caletrouinu  Susumuce  Comjiani}. 

Heati     O  ffi  ce: 

19.    GEORGE-STREET.    EDINBURGH. 

BOARD    OF    DIRECTORS. 
«bairman— THE  HON.  E.  C.  BULLER  ELPHINSTONE. 


A.   A.   Maconochie    Welwood,  Esq.,   of 

Meadowbank  and  Garvock. 
John  William  Young,  Esq.,  Writer  to  the 

Siornet. 
William  Stuart  Eraser,  Esq.,  Writer  to 

the  Signet. 
Peter  Home  Maclaren,  Esq.,  M.D. 
Thomas  Alex.  Hogg,  Esq.,  of  Newliston. 
Pairick  Stirling,  Esq.,  Younger,  of  Kip- 

pendavie. 


Sib  George  Wabrender,  of  Lochend, 
Bart. 

George  Readman,  Esq.,  9  Moray  Place, 
Edinburgh. 

John  Turnbdll,  Esq.,  of  Abbey  St. 
Bathans,  Writer  to  the  Signet. 

Charles  J.  Henderson,  Esq.,  6  Drura- 
sheugh  Gardens,  Edinburgh. 

Robert  Hotton  Leadbetteb,  Esq.,  Mer- 
chant, Glasgow. 


Manager  and  Actuary — D.  DEUCHAR,  F.I.A.,  and  F.F.A. 


DUBLIN  BRANCH— 31  Dame-street. 

Si?cfiBr.<Rr— JAMES  F.  WRIGHT.  |      ^ss/s r^ at. -Sbc— WILLIAM  COOTE. 

Medical  Off/cer— JAMES  LITTLE,  M.D.,  14  St.  Stephen's -green.  North. 

5oLfc/7-ofis— Messrs.  MEADE  &  COLLES,  8  Kildare  street. 

Bankers— TB.^  ROYAL  BANK  OF  IRELAND. 


Fire  Insurances. 

Insurances  against  loss  by  Fire  are  granted  on  the  most  favourable  terms.  The  Security 
is  unsurpassed,  the  proportionate  amount  of  Fire  Reserve  Funds,  as  compared  wit!)  the 
Premium  Income,  being  greatly  larger  than  in  the  case  of  most  other  offices.  Losses  by 
Lightning  are  admitted. 

Life  Assurance  on  unusually  favourable  terms- 

CLASS  Ai. — Moderate  Premiums,  with  Early  Bonuses,  which  may  be  applied  either  to 
increase  the  sum  assured  or  to  make  the  Policy  payable  during  life. 

CLASSES  A2  and.  B. — Lowest  Premiums,  \vith  special  Bonus  advantages  to  persons 
attaining  old  age. 

NEW  and  SELF-ACTING  NON-FORFEITABLE  SYSTEM.— 
Under  this  System  the  Surrender  Value  is  applied  to  pay  overdue  Premiums,  thus  pre- 
venting the  accidental  forfeiture  of  any  valuable  Policy.  Although  this  plan  is  new  in 
Great  Britain,  a  similar  plan  has  for  some  years  been  carried  on  with  much  success  in 
the  Australian  Colonies.  The  Australasian  Insurance  and  Banking  Record  concludes 
an  article  on  the  Non-Forfeitable  System  in  the  following  terms  : — 
"  It  is  to  the  credit  of  the  CALEDONIAN  that  it  should  be  the  first  to  introduce  this  liberal  feature  into 

practice  in  Great  Britain      As  the  precursor  of  a  new  and  better  state  of  things  in  the  Insurance  world  there 

it  ieserres,  as  we  trust  it  will  find,  its  reward  in  a  large  accession  of  business." 


New  Life  Assurances  in  7  years  ending  31st  December,  1874  £856,399 

New  Life  Assurances  in  7  years  ending  31st  December,  1881         .    £1,780.330 


T-.e  Fire  and  Mt{fe  Vtaintg  pairt  eacceetl  T«f-9  NliUionn  SSietHug, 


Miscellaneous  A  dverfisemen  tx . 


11 


Jolria.    I^iclxgi.r'clsoM.    &    Co., 

LEICESTER,    LIMITED, 
THE  LARGEST  MAKERS  OF  COATED  PILLS  IN  THE  WORLD, 

Beg  to  announct  that  they  have  opened  the  above  additional  extensive 
premises  for  the  sole  manufacture  of 

SOLUBLE     PEARL-COATED    PILLS. 

The  manufactory  being  fitted  throughout  with  Steam  power, 

and  containing  the  latest  and  most  improved  machinery,  the  firm  are 

enabled  to  offer 

1^  SPECIALLY    LOW   TERMS    TO    LARGE    BUYERS 

Price  List  of  over  830  Formulx  and  Special  Quotations  on  application. 

The  pill  making  Department  is  under  immediate  personal  super- 
vision, as  it  has  been  without  cessation  for  more  than  20  years  past. 


JOHN  RICHARDSON  &  CO.,  Leicester.  Limited. 


ESTABLISHED     1793 


^2  Dublin  Journal  of  Medical  Science. 

~  FANfNiINf  &  CO; 


IMPROVED 


CLINICAL  THERMOMETERS. 


_                                                                                                                                £    t.  d. 

Hospital  Clinical  Thermometers,  any  length,  in  ^ 

Cases  with  indestructible  Index,  2  J,  3,  3^,     >    2/-   &     0     2  6 

4,  5,  and  6  inches,  in  Metal  Cases  -  J 

Famiiii  &  Co.'s  Improved  Clinical  Thermometer,  do.  do.       -    0    3  0 

Fannin  &  Co.'s        do.             do.         with  flat  back             -     0     4  0 

Fannin  &  Co.'s  Improved  Minute  Thermometer   -            -    0    4  6 
Fannin    &    Co.'s    Improved    Half-Minute    Thermometer, 

round  -  -  -  -  .  -050 

Fannin    &    Co.'s  Improved   Clinical   Thermometer,   with 

Lens  Front  Magnifying  Index    -              -              -             -     0     7  0 
Fannin    &    Co.'s    Improved    Clinical     Thermometer,    in 

Bayonet-joint  Case         -  -  -  -  -070 

Fannin  &  Co.'s  Improved  Half-Minute  Thermometer,  with 

Lens  Front  and  Permanent  Index           -              -              -     0     8  0 

Hicks's  Patent  "  Non  Plus  Ultra"  Thermometers,  6/6,  7/6,  «fe  0    8  0 

Immisch's Patent  Metallic  Clinical  Thermometers,]    toia  o    ^     i  n 

in  Sterling  Silver,  very  portable               -              |    18/6  &    1     1  0 

Surface  Clinical  Thermometers,  in  various  1  -,  „  /e    i  k  /      »    -i     ■.  a 

shapes       ....         j- 13/6,  15/-    &   1     1  0 

Veterinary  Thermometers,  in  various  lengths,    "I      m/c  p    n  i/t  i\ 

enclosed  in  protecting  Tubes         -             -     j      ^"/o  «&   "  A*  " 

SPECIAL   QUOTATION    FOR    QUANTITIES. 


Certificates  of  Corrections  determined  hy  comparison  with  the  Standard  Instruments 
at  Kew  Observatory  supplied  with  each  Thermometer  for  Is.  (id.  extra. 

FANNIN  &  CO.  guarantee  every  Thermometer  they  supply  to  be  of  standard 

precision. 

BEEAKAGE  of  CLINICAL  THEEMOMETEES.— From  the  nature  of  their  con- 
struction, Clinical  Thermometers  are  exceedingly  fragile,  and  there  is  considerable 
risk  of  breakage  in  their  transmission  either  through  the  post  or  by  any  other 
mode  of  conveyance.  We  use  every  precaution  in  packing,  but  do  not  guarantee 
safe  delivery,  and  can  only  supply  them  at  the  risk  of  purchaBers. 


4:X      GRAFTON-STREET,     DUBILiIN. 

TELEPHONE  Mo.  198.    Telegrapliic  Address-*' FANNIN,  DUBLIN." 


Miscellaneous  Advertisements.  13 

SYR.  HYP¥hOS.  CO.,  FELLOWS. 

CONTAINS  THE  ESSENTIAL  ELEMENTS  of  the  Animal  Organi 
sation — Potash  and  Lime  ; 

THE  OXIDISING  AGENTS— Iron  and  Manganese  ; 

THE  TONICS— Quinine  and  Strychnine  ; 

AND  THE  VITALISING  CONSTITUENT— Phosphorus  :  the  whole 
combined  in  the  form  of  a  Syrup  with  a  SLIGHTLY  ALKALINE  RE- 
ACTION. 

IT  DIFFERS  IN  ITS  EFFECTS  FROM  ALL  ANALOGOUS  PRT^- 
PARA'I'IQnS  ;  and  it  possesses  the  important  properties  of  being 
pleasant  to  the  taste,  easily  borne  by  the  stomach,  and  harmless  under 
prolonged  use. 

IT  HAS  GAINED  A  WIDE  REPUTATION,  particularly  in  the 
treatment  of  Pulmonary  Tuberculosis,  Chronic  Bronchitis,  and  other 
affections  of  the  respiratory  organs.  It  has  also  been  employed  with 
much  success  in  various  nervous  and  debilitating  diseases. 

ITS  CURATIVE  POWER  is  largely  attributable  to  its  Stimulant, 
Tonic,  and  Nutritive  properties,  by  means  of  which  the  energy  of  the 
system  is  recruited. 

ITS  ACTION  IS  PROMPT;  it  stimulates  the  appetite  and  the  digestion, 
it  promotes  assimilation,  and  it  enters  directly  into  the  circulation  with 
the  food  products. 

The  prescribed  dose  produces  a  feeling  of  buoyancy,  and  removes 
depression  and  melancholy ;  hence  the  prepakation  is  of  great  value 
IN  the  treatment  of  mental  and  nervous  affections.  From  the 
fact,  also,  that  it  exerts  a  double  tonic  influence,  and  induces  a  healthy 
flow  of  the  secretions,  its  use  is  indicated  in  a  wide  range  of  diseases. 


NOTICE-CAUTION  —The  success  of  Fellows'  Syrup  of  Hypophosphites 
has  tempted  certain  persons  to  offer  imitations  of  it  for  sale.  Mr.  Fellows, 
who  has  examined  samples  of  several  of  these,  finds  that  no  two  of  them 
are  identical,  and  that  all  of  them  differ  from  the  original  in  composition, 
in  freedom  from  acid  reaction,  in  susceptibility  to  the  effects  of  oxygen 
when  exposed  to  light  or  heat,  in  the  property  of  retaining  the  strychnine 
in  solution,  and  in  the  medicinal  effects. 

As  these  cheap  and  inefficient  substitutes  are  frequently  dispense, 
instead  of  the  genuine  preparation,  physicians  are  earnestly  requested 
when  prescribing  the  Syrup,  to  write  "  Syr.  Hypophos.  FELLOWS." 

As  a  further  precaution,  it  is  advisable  that  the  Syrup  should  be 
ordered  in  the  original  bottles  (4/-  or  7/-) ;  the  distinguishing  marks 
which  the  bottles  (and  the  wrappers  surrounding  them)  bear,  can  then  be 
examined,  and  the  genuineness — or  otherwise — of  the  contents  thereby 
proved. 

BURROUGHS,  W^ELLCOME    &    CO., 
SNOW    HILL    BUILDINGS,    LONDON,    E.G. 


14 


Dublin  Journal  of  Medical  Science. 


Cocking's  Adaptable  Poroplastic  Jackets  and  Splints. 


Instructions  for  Measurement,  &c. 


«JJLCK[E2rF  {in  cases  of  slight  deformity). 

Circumference  at  nxilla. 
„  waist. 

„  hips. 

Length  from  axilla  to  great  trochanter. 

In  severe  angular  cases  circumference  over  apex  of 
curve,  position  of  same,  and  contour  should  be  gfiven  ;  in 
lateral  cases  a  description  of  the  case. 

In  all  cases  it  should  be  stated  if  for  male  or  female. 


A 

CERYICAIL.   JACKET. 

Same  measurements  required,  and  circumference  at  neck, 
and  length  from  neck  to  axilla. 

III 

Any  part  of  the  Jacket  can  in  the  process  of 
Manufacture  be  left  Soft. 

s 

CX^UB    FOOT. 

Circumference  below  knee. 
„                 ankle. 
„                heel  and  instep. 
Length  from  below  knee  to  ground. 
„        of  foot. 

SOLE  AGENTS  FOR  DUBLIN— FANNTN   &  CO., 

Manufacturers  of  Surgical  Instruments  &  Appliances,  Medical  Booksellers  &  Publishers, 
41    GRAFTON-STREET,    DUBLIN. 


Miscellaneous  A  dvertisements. 


15 


Cooking's  Adaptable  Poroplastic  Jackets  and  Splints. 


Instructions  for  Measurement,  &c. 


Circumference  at  waist. 

„  hips. 

„  thigh,  top  of 

„  above  knee. 

Length  from  waist  to  groin. 

State  If  for  right  or  left  side. 


Circumference  at  top  of  thigb. 

I,  above  knee. 

„  at  knee. 

K  below  kneei. 

,1  calf. 

„  ankle. 

Length  from  groin  to  centre  of  knee. 

„         centre  of  knee  to  ankle. 
State  If  for  right  or  left  leg. 

When  the  foot-part  is  required,  also  circumference  of 
heel  and  instep,  and  length  from  centre  of  knee  to 
ground. 

If  the  limb  ia  contracted  the  contour  should  be  given. 


Splints  are  also  made  in  Poroplastic  for  fracture  of  Inferior  Maxilla,  EumeniA 
Elbow- Joint,  Forearm,  Thigh,  Knee-Joint,  Leg,  Shoulder-Joint,  Band,  tie. 

These  Splints  can  be  fitted  perfectly  to  the  Patunt  if  softened  either  by  hot  water  or  in 
a  Beater  made  for  the  purpose.  When  mounted  with  vebbing,  hot  water  will  do ;  if  with 
leather,  a  Beater  should  be  used.  The  material  becontu  guite  hard  again  in  two  or  three 
minutes. 

SOLE  AGENTS  FOR  DUBLIN— IF ANNTJff    &   CO., 
Mannfacturers  of  Surgical  Instruments  &  Appliances,  Medical  Booksellers  &  Publisliers, 

41    GKAFXOIX-SXRELEX,    DXJBLIIN. 


W\^D's  Soluble  Pearl-Coated  Pills. 

SIF*  E30£.^.1Li    I*I1>J'.ESS.       (EXTRA.    DISCOtrJSTTS.) 

7i  per  cent,  on  an  or^ler  for  five  10  gross  tins  assorted,  or  50  (tro^s  of  any  one  kind.      )  Carriage  Paid  in 
10  per  cent,  on  an  order  for  ten  lO-jjross  tins  assorted,  or  100  gross  of  any  one  kind.  )      Great  Britain. 

" "• •     '"  """""  TINS.     CARRIAGE  PAID  in  Great  Britain. 


NET  FOR  CASH  WITH  ORDER,  in  lO-GROSS 
OfBclal  Formulas. 


3  Pit  A.LOBS  ST  Fkrri, 
6    „     AsAFoeTiDA  Co., 

8  ,,      COLOCTNTH  Co., 

9  „      COLOCTNTH  «T  HTOS., 

13    „     Htdraro., 
17    „    Rdsi  Co., 


Per  Gross 
8.    d. 

-  U    6^ 

-  0     S 

-  0 

-  1 

-  0 
.    0 


Aperient  Pills. 

45  Ext.  Aloes  Aquosum  gr.  xx. 

PuIt.  Carabogie  „    it. 

„      Jalaps  .,    »iij- 

„      Colocvnth  „    vi. 

„      Hyd.  Subchlor.  „    iv. 

.,      Sapo.  Hyspan.  „    iv. 

Gingerin.  .,    ij- 

Ft.  Pil.  xlj. 

Ench  Pill  eontiins  Calomel,  l-8th  gr. 

46,  as  45.  with  1  gr.  Calomel, 

47.  a.s  45,  sine  Calomel, 

533    vloes  Barb.,  gr.  iss. 

Jalaps,  ,,   ■- 

Coloc,  .,   i. 

CambogiB,  ,.  l-4th 

Saponis,  ,,  ss. 

01.  Ctrui,  gtt.  l-4th 
40  Ai.oiN. 

Jalapin,  wu  gr.  i. 

Gingerin,  ,,  1-I6th  - 

Antlblltous. 

129  Pil.  Htdraro.,  gr.  i. 
Ext.  Coloc.  Co.  ,,  ij. 

,,     Hyoscy.,  ,,  i.      - 

130  Pil.  Htdraro.,  ,,  i. 

,,     Rhei  Co.  ,,  iv.    - 
865  Hydraro.  Subchlor.,        ,,  iss. 

Pil.  Coloc.  Co.,  ,,  iij.    - 

1083  I'ODopBTLLty,  ,,  l-4th 

Ext.  Coloc.  Co.,  „  ij. 

,,     Hyoscy.,  „  i.       - 

187  PonoPHTLLiK,  ,,  l-4th 

188  PODOPHTLUN,  „   8S.       - 

Cascara  Sagrada. 

70  Ext.  Cascara  Sagrada,    gr.  ij.     - 

71  Exr.  Cascar\  Sagrada,     ,,  iv.     - 

72  KxT.  Cascara  Saorada,      „  ij. 

„       Nuc.  Vera.  Ale. 
„      Belladonns,  aa.  gr.  l-8th 

Gentian,  ,,    ss.    - 

435  Ext.  Cascara  Saorada,    ,,  ij. 
„     Nuc.  Vom.  Ale. 
„     Hyoscyam.,  a».  gr.  1  8th 

„    G«ntian,  gr.  ss.    - 


10 
0 
6 
5i 


1      8 


0  11 

0  8 

1  2 


1  2 
0  6 
0     8 


1     0 


1    0 


Calcll  Sulphide. 

63  Calcii  Sdlphid.,  gr.  l-4th         -    0    8 
409  Calcii  Sclphid.,  „  ss.  -    0    8 

64  Calcii  Sdlpuid.,  „  i.  -08 

Ctiamomlle  and  Rhubarb  Pills. 

gr.  isi. 


43  Ext.  Anthem., 
Pulv.  Rhei, 
,,     Zingib, 
,,     Aloes  Soc. 


-    0 


Digestive  Pills. 


60  BrsMCTH  Sobnit., 

Soilii  Bicarb., 

Ext.  Nucis.  Vom. 

Gingerin, 
147  PULV.  IPECAC.  CO., 
98  BRGOTIN. 

Ferri  Sulph.  Ezsic. 

Ext.  Hellebor. 
,,     Aloes  Soc., 

01.  Sabins, 


gr-  ']• 


1-lOth 
l-4tb 


Per  Gross 
s.    d. 


0  10 
0  10 


as.  gr.  1. 

gtt.  S3.     - 

Pil  Ferri  lodid. 

667  Pil.  Ferri  Iodid.,  gr   ij.  or  Iij. 


IV.  or  V. 
ij- 


l-32nd. 
q.s. 


1    9 


l-8th 


666    „     FsRRi  Iodid.,  P.B. 
665     .,     Ferri  Iodid., 

Quininae  Suiph , 
670  Ferri  Phosphate. 

Quininae  Sulph.,  a 

Strychninae, 

Acid  Pliosph.  Con., 

(Pil  Bastonii.) 

Gout. 

472  Ext.  Colchici. 

Ammon.  Carb.,  aa.  gr.  l-4th 

Guaiacl  Res.  ,,  iv. 

Pulv.  Opii., 
476  Ext.  C.)L0HICI  Acet. 

Pil.  Hydrarg. 

Ext.  Aloes.  .Socot. 

Pil.  Rhei  Co.,  aa.  gr.  i..        -    0  10 

Mercurial  Pills. 

116  Htdraro.  c.  Oreta,  gr.  iij.  -  0  9 

117  Htdrarg.  c.  Crkta. 

Pulv.  Ipecac.  Co.,  aa.  gr.  i.  -  0  9 

141  Htdraro.  Sdbchlor  ,          „  ss  -  0  6 
8J0  Hvdrarg.  Stbchlob.,          „  i.  -  0  6 

142  Htdraro.  S0BCHLoa.,          ,,lj.  -  0  6 

Sedative  Pills. 

937  MoRPH.  MuR.,  gr.  l-4th.     -     1     IJ 

162  Pulv.  Opii,  „  gr.  ss.      -    0    9 

163  Pdlv.  Opii  ,  „  i.  -    1    1 

Potas.  Permang. 

(Our  exceptionally  small  Pills.) 

199  PoT.is.  PsEMAKO.,         gr.  i.  -  0     6 

200  Potas.  Permang.,           „  ij.  -  0     9 
1142  Potas.  Permano.,           „  iij.  -  0  10 

QuinsB  Sulph.,  B  P. 

gr.  I  -  10  Gross  at  4Jd.  per  Grou. 

„  i.  -  10        „        5Jd. 

„  ij.         -  10        „        9d. 

.,  iij.         -  10        „        Is.  Id.    „ 

1155  Qoiketi.         ''^*'  Pills. 

Ferri  Sulph.,  aa.  gr.  ss. 

Ext.  Belladonns,  gr.  l-4tb. 

„    Colch.  Acetat.,  ,,  ss. 

,,    Hyoscy. 
CamphorsB,  aa.  gr.  i.         -     1     0 

Tonic  Pills 


-    0     9 


109  Pil.  Ferri  (Blacd), 

170  Phosphori  Pub., 

171  Phosphori  Pdb., 
173  Phosphori  Pcr., 

Quiniiis  Sulph., 
177  Phosphori  Pob., 
Ferri  Kedaoti, 
Quininae  Sulph., 
Strychnina, 


0  4} 
1  6 
1    6 


gr.  iv.  and  v.- 
„  l-.30th  - 
,,  l-30th  - 
„  l-3uth 

',',  l-30th 
„  iij- 


l-30th      -    2    0 


OUR    LIST    CONTAINS     1  2  9  -i     FORMULA. 

Special  Prices  for  6O0  or  lOOO  Gross  lots  of  Pearl  or  Gelatine  Coated. 

PRIVATE    FORniUI..£    QUOTED    FOR. 

WAND,  PEARL-COATED  PILL  FACTORY,  Leicester. 


l^KRIODICALS  WITH   WHICH   THE  DUBLIN  JOURNAL   OJ? 
MEDICAL   SCIENCE   IS   EXCHANGED. 


OHBAT  BBITAlM . 

1.  The  Edinburgh  Medical  Journal. 
Oliver  and  Boyd. 

2.  The  Retrospect  of  Medicine.  Edited 
by  James  Braithwaite.  Simpkin,  Mar- 
shall, and  Co. 

3.  PharmaceuticalJournal.    Churchill. 

4.  The  Lancet. 

5.  The  British  Medical  Journal. 

6.  The  Journal  of  Mental  Science. 
London  :  Churchill. 

7.  The  Glasgow  Medical  Journal. 
A.  MacDougiill. 

8.  The  Medical  Press  and  Circular. 

9.  The  Westminster  Review.  Trubner. 

10.  Transactions  of  Obstetrical  Society. 
London  :  Longmans. 

11.  The  Practitioner  ;  a  Monthly  Jour- 
nal of  Therapeutics.     Macinillau  and  Co. 

12.  The  Journal  of  Anatomy  and 
Physiology.     Macmillan. 

13.  Brain.     London  :  Macmillan  &  Co. 

14.  The  Bristol  Medico-Chirurgical 
Journal. 

16.  The  Provincial  Medical  Journal. 

17.  The  British  Journal  of  Dercaatology. 

CANADA. 

15.  The  Montreal  Medical  and  Surgical 
Journal.  Richard  White.  Box  386,  P.O., 
Montreal. 

AMKBICA. 

19.  The  American  Journal  of  the 
Medical  Sciences.  Edited  by  Isaac 
Hayes,  M.D.  Philadelphia:  Henry  C. 
Lea.     London:  Trubner  and  Co. 

20.  The  Medical  Record.  New  York : 
William  Wood  &  Co. 

21.  Medical  News.  Philadelphia  : 
Henry  C.  Lea's  Son  and  Co. 

22.  The  American  Journal  of  Science 
and  Arts.  Conducted  by  Professors  B. 
Silliman,  and  J.  D.  Dana,  &c.  New 
Haven:  Editors. 

23.  The  American  Journal  of  Insanity, 
Utica,  N.  Y.     State  Lunatic  Asylum. 

24.  The  American  Journal  of  Obstetrics 
and  Diseases  of  Women  and  Children. 
New  York  :  William  Wood  and  Company, 
London  :  S.  Low,  Son,  and  Marston. 

25.  The  New  York  Medical  Journal. 
New  York  and  Loudon :  D  A.ppleton&  Co. 

26.  The  Medical  and  Surgical  Reporter. 
Philadelphia :  N.  A.  Randolph,  M.D., 
and  Charles  W.  Dulles,  M.D. 

27.  Journal  of  Cutaneous  and  Venereal 
Dibeafes,  New  York :  Wm.  Wood  and  Co. 


AUXSIOA. — continued. 

28.  The  Times  and  Register.  New 
York  and  Philadelphia. 

29.  Chicago  Journal  of  Nervous  and 
Mental  Disease. 

30.  The  St.  Louis  Medical  and  Surgical 
Journal.  St.  Louis  :  Geo.  0.  Rumbold 
and  Co. 

31.  Journal  of  the  American  Medical 
Association.     Chicago,  Illinois. 

32.  Index  Medicus.  George  S.  Davis. 
Detroit,  Michigan. 

33.  The  Occidental  Medical  Tim^. 
James  H.  Parkinson,  Editor,  Sacramento, 
California. 

FBANCE. 

34.  Repertoire  de  Pharmacie,  Archivo* 
de  Pharmacie,  et  Journal  de  Chimie 
Mddicale  r^unis.  Troisi^me  Sdrie.  Paris  ; 
M.  C.  Crinon. 

35.  Gazette  M^dicaie  de  Paris,  Paris : 
4,  Place  Saint-Michel. 

36.  Journal  de  Pharmacie  et  de  Chimie 
&c.     Paris  :  Victor  Masson. 

37.  L' Union Medicale.  Paris:  Bureau, 
Rue  de  la  Grange  Batelifere. 

38.  Archives  Gdn^rales  de  Mddeoine. 
Paris:  Asselin. 

39.  Bulletin  del'AcadtSmie  de  M^decine. 
Paris  :  G.  Masson. 

40.  Revue  de  Th^rapeutique  M^co- 
Chirurgicale.      Paris  :  Masson. 

41.  Anne.les  Medico  -  Psychologiquen. 
Par  MM.  Baillarger,  Cerise,  et  Limire. 
Paris:  V. Masson. 

42.  Bulletin  G^n^ral  de  Th^rapeutique. 
Medicale  et  Chirurgicale.  Par  le  Docteur 
F^lix  Bricheteau.     Paris. 

43.  Repertoire  de  Pharmacie.  Par  M. 
Eug.  Lebaigue.  Paris :  Rue  de  la  Perle,  1 1. 

44.  Annales  de  Gyn^cologie.  Paris  : 
H.  Lauwereyns. 

45.  Gazette  des  HOpitaux.  Paris :  i. 
Rue  de  I'Odbon. 

46.  Lyon  Medical,  Organe  Officiel  de  I* 
Society  Imperiale  de  M^decine.  Lyon  . 
M  egret. 

47.  Revue  des  Sciences  M^dicales  en 
IT  ranee  et  k  I'^tranger.    Paris :  G.  Masson, 

48.  Gazette  Hebdomadaire.  Paris : 
91,  Rue  de  Lille. 

49.  Revue  de  Medecine  et  Revue  de 
Chirurgie. 

50.  Kevue  de  Laryngologie,  d'Otologie, 
et  de  Rhinologie,     Paris  :  Octave  Doin. 

51.  Annales  des  Maladies  des  Organes 
Genito-Urinaii-es,  Paris  :  22,  Place  St. 
Georges. 


List  of  Exchange  Journata. 


BELGIUM. 

51.  Bulletin  de  I'Acad^mie  Rovale  de 
M^decine  de  Belgique.  Bruxelles  :  F. 
Hayez. 

52.  AnnalcR  d'Ocuiistiqiie.     Bruxelles. 

GERMANY. 

53.  Archiv  fiir  Gynaekologie.  Redigirt 
von  Cred^  und  Spiegelbeig.  Berlin : 
Axigust  Hirschwald. 

54.  Centralbliitt  fiir  die  medicinisclien 
Wissenscbaften.  Berlin  :  August  Hirscli- 
waid. 

00.  Jahrbuch  fiir  Kinderheilkunde  nnd 
pbysische  Erziebung.  Leipzig:  B.  G. 
Teubner . 

56.  Arcbiv  fiir  pathologische  Anatomi 
nnd  Pliysiologie,  &c.  Herausgegeben  von 
R.  Virchow.    Berlin:  G.  lieimer. 

57.  Berliner  klinisclie  Wociienschnft 
Berlin  :  Hirschwald. 

58.  Archiv  fiir  klinische  Chirurgie. 
Herau.sgegeben  von  Dr.  B.  von  Langen- 
beck.     Berlin:   Hirschwald. 

59.  Archiv  fiir  Psychiatric  nnd  Nerven- 
krankheiten.  Berlin  :  August  Hirsch- 
wald. 

60.  Zeitschrift  fiir  physiolngische 
Chemio.  Herausgegeben  von  F.  HDppe- 
Seyler.     Strassburg  :  Karl  J.  Trubntir. 

61.  Deutsche  Medlzinal-Zeitiing.  Her- 
ausjjegeben  von  Dr.  Julius  Grosser. 
Berlin  :  Eugen  Grosser. 

62.  Albrecht  von  Graefe's  Archiv  fiir 
Ophthalmologie.  Gottiugen  :  Professor 
Dr.  Th.  Leber. 

63.  Centralblatt  fiir  klinische  Medicin. 
und  Centralblatt  fiir  Gynakologie.  Berlin ; 
Hirschwald. 


NOKWAT. 

64.  Norsk  Magazin  for  Laegeviden- 
skaben.  Udgivet at  det  medicinske  iSelskab 
i  Christiania.  Christiania:  PaaTh.  Steea, 
Forlag. 

SWEDEN. 

65.  Hygiea,  medicinsk  och  farma- 
ceutisk  Maonads-.skrift.  Stockholm :  P. 
A.  Norstedt  och  Soners  forlag. 

66.  Nordiskt  medicinskt  Arkiv.  Re- 
digeradtaf  Dr.  Axel  Key,  Prof,  i  Patolog, 
An;\t.  i  Stockholm.  Stockholm:  Samson 
och  VVallin. 

67.  Upsala  Liikareforenings  Forhand- 
ingar.     Upsala  :  Ed.  Berling.  - 


68.  Hospitals-Tidende.  Optegnelseraf 
praktisk  Lsgekunst  fra  Ind-  og  tJdlandet. 
Kjobenhavn  :  Jacob  Lund.  London  : 
Asher  and  Co. 

69.  Bibliothek  for  Laeger.  Kjoben- 
havn :  C.  A.  Reitzels  Forlag. 

70.  Utreskrilt  for  Lseger.  Kjobenhavn  : 
C.  A.  Reitzels  Forlasr. 


71.  Lo  Sperimentale,  Giornale  Cntico 
di  Medicina  e  Chirurgia  per  servire  ai 
Bisogni  dell'  Arte  Salutare.  Direttore 
Prof.  C.  C.  M.  Butalini.  35,  ViaAlfani, 
Florence. 

AUSTRALASIA. 

72.  The  Austriihaian  Medical  Gazett". 
Sydne;^  :  L.  Bruck. 


BOOKS,  PAMPHLETS,  AND  PERIODICALS  RECEIVED— JULY,  1892. 


1.  Bulletin  of  the  Harvard  Mpdical 
School  ABSociation.  No.  2.  Catalogue. 
BoBton.     1892.     Pp.  70. 

2.  On  Contractions  of  the  Fingers  and 
on  "  HRHimer-Toe."  Ey  Williain  Adams, 
F.R.C.S.  Encr.  Second  Edition.  Loudon: 
J.  &  A.  Churchill.    1892.    8vo.    Pp.  154. 

3.  The  Diagnoses  of  Syphilis.  Bv 
John  Kellock  Barton,  M.D.,  F.R.C.S.I. 
Dublin  :  Fannin  &  Co.  1892.  Third 
Edition.     Pp.  27. 

4.  Europhen  in  der  Augenheilkunde. 
Von  Dr.  D.  Juan  Santos  Fernandez. 
Uebersetzung  aus  Cronica  Medica-Quir- 
drgica  de  la  Habana.  Band  XVII.  No. 
2i.,  p.  800.     Pp.  4. 

6.  City  Hospital,  Birmingham.  Annual 
Report  for  the  year  1891.  By  N.  S. 
Manning,  F.R.C.S.I.,  Medical  Superin- 
tendent. BiriLingham :  Geo.  Jones  & 
Son.     Pp.  19. 

6.  World  Wide  Missions.  Vol.  IV. 
Nob.  10  and  11.  May  and  June,  1892. 
New  York  and  Chicago. 

7.  Thirty-first  Annual  Report  of  the 
Cincinnati  H>>spital  for  the  year  ending 
December  31st,  1891.  Cincinnati.  1892. 
Pp.  99. 

8.  The  Essentials  of  Histology.  By 
E.  A.  Schafcr,  F.K.S.  Third  Edition. 
London  :  Ijongmans,  Green,  &  Co.  1892. 
8vo.     Pp.  302. 

9.  Microscopical  Observations  on  the 
Blood  and  Excreta  in  cases  of  Cholera. 
By  Surgeon  Patiick  Hehir,  M.D., 
F.RC.S.E.  Indian  Medical  Gazette. 
April,  1892. 

10.  Pathological  and  Etiological  Rela- 
tions of  Tropical  Suppurative  Hepatitis. 
By  Surgeon-Captain  Patrick  Hebir.  M.D., 
F.R.C.S.E.  Madias :  G.  W.  Taylor. 
Pp.  19. 

11.  The  Wills  Eye  Hospital.  Reports 
for  1890  and  1891.  Philadelphia.  1891 
and  1892.     Pp.  26  and  26. 

12.  On  a  Condition  of  the  Urine  met 
with  in  Phthisis.  By  W.  Hale  White, 
M.D.,  F.K.C.P.    Reprint.    1892.    Pp.  4. 


13.  Pevue  G^n^mle  de  M^decine.  de 
Chirurgie,  et  d'Obst^trique.  Premiferu 
Anii^e.  Juin,  1892.  No.  22.  Paiia : 
O,  Doin. 

14.  Diseases  of  the  Rectum  and  Anus. 
By  Alfred  Cooper,  F.R.C.S.,  and  F. 
Svvinford  Edwards,  F.R.C.S.  Second 
E  iition.  London  :  J.  &  A.  Churchill. 
1892.     8vo.     Pp.  324. 

15.  M^moires  couronnds  et  autres 
M^moires  publics  par  I'Acad^mie  Royals 
de  M^decine  de  Belgique.  Tome  XI. 
Troisifeine  et  Quatrleme  Fascicules. 
Bruxelles  :  F.  Hayez.     1892. 

16.  Remarks  on  Thorough  Operations 
for  Cancer  of  the  Female  Breast.  By 
W.  Roger  Williams,  F.  R.C.S.  Eng.  Pp.  4. 
1892.     Manchester  :  John  Hey  wood. 

17.  Medical  Electricity.  By  W.  E, 
Steavenson,  M.D.,  and  H.  Lewis  Jones. 
M.A.,  M.U.  London:  H.  K.  Lewis. 
1892.     8»o.     Pp.  446. 

18.  The  Medical  Bulletin.  Vol.  XIV- 
No.  5.  May,  1892.  Philadelphia:  F- 
A.  Davis  Co. 

19.  The  Abstract  And  Index.  Vol. 
VIL  No.  1.  April,  1892.  Weston,  Vt.: 
H.  H.  Howe. 

20.  The  National  Bulletin.  Nos.  8l» 
82,  and  83.     June,  1892. 

21.  The  Medical  Reporter.  Volume  I. 
Nos.  1,  2,  3,  4,  6,  6.     Calcutta.     1892. 

22.  A  Mmual  of  Chemistry.  By 
Aithur  P.  Luff,  M.D.,  B..Sc.  (Lond.), 
M.li.C.P.  London:  Ca88ell&  Co.  1892. 
8vo. 

23.  Historical  Retrospect  of  Sanitation- 
By  Surgeon-Captain  Patrick  Uehir,  M.D.. 
F.R.C.S.E,     Pp.  26. 

24.  Two  successful  cases  of  the  Conser- 
vative Caisarean  Section.  By  Charles 
Jewett,  A.M.,  M.D.  Brooklyn,  N.Y. 
Reprint.     Pp.  9. 

25.  To  what  extent  is  the  Diagnosis  of 
Pregnancy  possilile  in  the  early  months  V 
By  Charles  Jewett,  M.D.  Pp.8.  1891, 
Reprint, 


Book»,  PamphJefft^  and  Periodicah  received — (eontimt^d). 


26.  The  Pharmaceoticul  JonrnJil  of 
AnitraUsia.  Vol.  V.  No.  4.  Sydney. 
April  25,  1892.     [Duplicate  copies.] 

27.  Medical  Review.  Vol.  XXV.  No. 
23.     St.  Louis,  Mo.     June  4,  1892. 

28.  A  Handbook  of  Hygiene  and  Sani- 
tary Science.  By  George  Wilson,  M.A., 
M.D.,  F.R.S.  Edin.,  D.P.H.  Camb. 
Stventh  Edition.  London  :  J.  &  A. 
Churchill.    1892.     8vo.     Pp.  751. 

29.  Transactions  of  the  American 
Orthopedic  Association.  Fifth  Session. 
Volume  IV,     Philadelphia.     1891. 

80.  Printers'  Ink.  Vol.  VI.  No.  23. 
New  York.     June  8.  1892. 


31.  Fourth,  Fifth,  and  Sixth  Annual 
Reports  of  the  State  Board  of  Health 
and  Vital  Statistics  of  the  Commonwealth 
of  Pennsylvania.  Harrisbur^  :  Edwin 
K.Meyers.     1889.     1890.     1891. 

32.  Proceedings  of  the  Newport  Natural 
History  Society,  1)?88-1891.  Extract 
from  Document  VIII.  Ne\vport,  R.  I. 
1892.     Pp.  29. 

33.  The  Journal  of  the  British  Dental 
Association.  Vol.  XIII.  No.  6.  June 
15,  1892.  London  :  Baillifere,  Tindall  &, 
Cox. 

34.  Doctors'  Magazine.  Vol.  I.  No.  S. 
June,  1892.  Bombay  :  K.  Nadkarni. 
1892. 


THE    DUBLIN    JOURNAL 

OF 

MRDTOAL    SCIENCE. 
CONTENTS. 


Third  Series,  No.  CCXLVTI.— JULY  1.  1892. 


Part  I._0RIGINAL  COMMUNICATIONS . 

PAOS 

Art.  I — Clinical  Observations  on  Pleural  Effusion  with  Displacement 
of  the  Heart.  By  W.  Laxgford  Symes,  L.R.C.P.I.,  &c.,  Kiltegan, 
Co.  Wicklow_(IIlu9trated),  ....  -  1 

Art.  IL— Trephining  for  Meningitis.  P.y  J.  S.  M'Ardle,  F.R.C.S.T.  : 
Surgeon  and  Lecturer  on  Clinical  and  Operative  Surgery,  St. 
Vincent's  Hospital — (Illustrated),  -  -  -  -         17 

Art.  III. — The  Desirability  of  Operative  Interfeionce  in  Suspected 
Perforation  of  Chronic  Ulcer  of  the  Stomach.  By  Alfued  R. 
Parsons,  M.B.  (Univ.  Dubl.)  ;  late  House  Surooon  in  Sir  P.  Dun's 
Hospital,    ----..--         26 

Art.  IV — Notes  on  Epidemic  Influenza,  1891-92.  By  E.  MacDowel 
CoSGRAVE,  M.D.,  F.l;  C.P.I. ;  Physician  to  Whitworth  Hospital, 
Drumcondra,  and  Cork -street  Fever  Hospital :  Professor  of  Biology, 
Royal  College  of  Surgeons,  -  -  -  -  -         S5 

Part  II.— REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 

1.  Bacteriological  Diagnosis:  Tabular  Aids  for  Use  in  Practical  Work. 

By  James  Eisenberg,  Ph.D.,  M.D.  Translated  and  augmented, 
with  the  permission  of  the  Author,  from  the  Second  German 
Edition,  by  Norval  H.  Piercf,  M.D.,      -  -  -  -         .39 

2.  The  Principles  and  Practice  of  Medicine,  designed  for  the  use  of 

Practitioners  and  Stmh-nts  of  Medicine.  By  Wit.mam  Osler, 
M.D.,  F.R.C.P. ;  Professor  of  Medicine  in  the  Johns  Hopkins 
University;  Physician-in-Chief  to  the  Johns  Hopkins  Hospital. 
Baltimore;  formerly  Professor  of  the  Institutes  of  Medicine,  M'Gill 
University,  Montreal ;  Professor  of  Clinical  Medicine  in  the  Uni- 
versity of  Pennsylvania,      .--...         40 

3.  Royal   University  of  Ireland.     The   Calendar   for   the  Year    1892. 

Examination  Papers,  1891,  -----         42 


ii  Conteitii. 

PAOl 

4.  A  Treatise  on  the  Ligation  of  the  Great  Arteries  In  Continuity,  with 

Observations  on  the  Nature,  Progress,  and  Treatment  of  Aneurysm. 
By  Charles  A.  Ballance,  M.S.,  &c.,  and  Walter  Edmunds, 
MC,  &c.,  ...-..-         43 

5.  Tuberculosis  and  its   Successful  Treatment.      By  Robert  Bell, 

M.D.,  F.F.P.  &S.,  «6c, ;  Senior  Physician  to  the  Glasgow  Hospital 
for  Diseases  Peculiar  to  Women,  &c.,  -  -  -  -         46 

6  Differentiation  in  Rheumatic  Diseases  (so-called).  By  Hugh  Lane, 
L.R.C.P.,  M.R.C.S. ;  Surgeon  to  the  Royal  Mineral  Water  Hos- 
pital, Bath;  Hon.  Medical  Officer  to  the  Royal  United  Hospital, 
Bath,  ..-..---        46 

7.  Essays  on  Acromegaly.     By  Dr.  Pierre  Marie  and  Dr.  Souza- 

Leite  ;  with  Bibliography  and  Appendix  of  Cases  by  other  Authors,         47 

8.  The  Water-Cure  in  the  Bedroom ;  or,  Hydropathy  at  Home.     By 

G.  H.  DouDNEY,  M.B.,  M.R.C.S.  Eng.;  late  Resident  Medical 
Officer  to  the  Seamen's  Infirmary,  Ramsgate,  -  -  -         48 

9.  The  Diseases  of  the  Nervous  System.     By  J.  A.  Ormerod,  M.A., 

M.D.,         -  -  -  -  '-  -  -  -         4S 

10.  The  Dietetic  Value  of  Bread.     By  John  Goodfellow,  F.R.M.S.,        49 

1 1.  An  Index  of  Diseases  and  their  Treatment.  By  Thomas  Hawkes 
Tanner,  M.D  ,  F.L.S.  Fourth  Edition,  revised  by  Percy  Boulton, 
M.D.,  M.R.C.P.,  London  ;  Senior  Physician  to  the  Samaritan  Free 
Hospital,  &c.,         -.----.         51 

1 2.  Die  Behandlung  der  Tuberculose  mit  Tuberkulocidin.  Verlaufige 
Mittheilung  von  Professor  D.  E.  Klebs  in  Zurich,  -  -         .">^ 

•  3.  The  Essentials  of  Histology,  Descriptive  and  Practical,  for  the  Use 

of  Students.     By  E.  A.  Schafer,  F.R.S.     Third  Edition,  -         62 

1 4.  The  New  Sydenham  Society's  Lexicon  of  Medicine  and  the  Allied 
Sciences.  (Based  on  Mayne's  Lexicon  )  By  Henry  Power,  M.B., 
and  Leonard  W.  Sedgwick,  M.D.     Part  17.     Mas-Mit,  -        53 

16.  Materia  Medica  and  Therapeutics.  Vol.1.:  By  J.  V.  Shoemaker, 
M.D.,  and  J.  Aulde,  M.D.  1889.  Vol.  IL :  By  J.  V.  Shoe- 
maker, M.D.     1891,  -  -  .  -  .  -        53 

16.  Lemons  de  Th^rapeutique.  Par  G.  Hayem.  3""=  Serie.  Les  Medi- 
cations,      -.-.---.54 

17.  Lectures  on  Children's  Diseases.  By  Dr  K.  Henoch.  Vol.  II. 
Translated  from  the  Fourth  Edition  (1889)  by  J.  Thomson,  M.B., 
F.R.C.P.  Edin., 54 

18.  The  Lord  of  Humanity,  or  the  Testimony  of  Human  Consciousness. 

With  Supplement  on  the  Mystery  of  Suffering.  By  Frederick 
James  Gant,  F.R.C.S.     Second  Edition,  -  -  -        .ii 

19.  Pye's  Surgical  Handicraft.     Third  Edition.     Revised  and  Edited 

by  T.  H.  R.  Crowle,  F.R.C.S.,  &c.,  -  -  -  -         56 

'ZO.  Abdominal  Surgery.    By  J.  Greig  Smith,  M.A.,  F.R.S.E. ;  Surgeon 

10  the  Bristol  Royal  Infirmary,  «fec.     Fourth  Edition,        -  -         56 


ConUntn.  in 

PAOB 

21.  Materia  Medica,  Pharmacy,  Pharmacology,  and  Therapeutics.     By 

W.  Hale  White,  M.D.,  F.R.C.P.,  "  -  -  -  -        57 

22.  The  Rheumatic  Diseases  (so-called),  with  Original  Suggestions  for 
more  Clearly  Defining  Them.  By  H.  Lane,  L.R.C.P.  Edin.,  and 
C.T.  Griffiths,  L.R.C. P.  Lend.,'  .  -  .  .        57 

23.  Tables  for  the  Diagnosis  and  Treatment  of  Syphilis.     By  J#  K. 

Barton,  M.D.,  Senior  Surgeon  to  the  Adelaide  Hospital,  and  Past 
President,  R.C.S.I.     Third  Edition,  -  -  -  -        58 

Part  IIL—SPECIAL  REPORTS. 

Report  on  Public  Health,  By  Sir  Charles  A.  Cameron,  M.D.  ; 
ex-President,  DIplomate  {Honoris  Causa)  in  Public  Health,  and 
Professor  of  Chemistry  and  Hygiene,  R.C.S.I. ;  President  of  the 
British  Institute  of  Public  Health,  and  of  the  Irish  Medical 
Association;  Examiner  in  Sanitary  Science,  Royal  University; 
D.f.H.  (Camb.)  ;  Medical  Officer  of  Health  for  Dublin,  &c.  :— 
On  some  Points  in  the  -Etiology  of  Typhoid  Fever — (Illustrated),         .!>9 

Part  IV.— MEDICAL  MISCELLANY. 

Royal  Academy  of  M^dicink  in  Ireland: — 
section  of  medicine. 
The  Desirability  of  Operative  Interference  In  Suspected  Perforation 

of  Chronic  Ulcer  of  tlic  Stomach.     By  Dr.  Par.sons,      -  -  76 

Detachment  of  Retina.     By  Mr.  Story,    -  -  -  -         78 

SECTION   OF    SURGERY. 

Trephining  in  Cerebral  Meningitis.     By  Mr.  M'Ardle,    -  -         78 

Electrolysis  In  Affections  of  the  Male  Urethra.     By  Dr.  Pearson,         79 

Sanitary  and  Meteorological  Notes.  Compiled  by  J.  W.  Moore. 
B.A.,  M.D.,  Univ.  Dubl;  F.R.C.P.L;  F.R.Met.  Soc;  DIplo- 
mate in  Stafo  Medicine  and  ex-Sch.  of  Trin.  Coll.  Dubl.: — 

Vital  Statistics  for  Four  Weeks  ending  Saturday,  May  21,  1892.         82 
Meteorology — Abstract  of  Observations  made  at  Dublin  for  Month 

of  May,  1892,     --.----         87 

Periscope  : 

Treatment  of  Tuberculosis  by  Iodoform  Inunctions,  -  -  .38 

Simple  Urinary  Tests,         -  -  -  -  -  -  81 

Ehrlich's  Test  of  Urlno  in  Typhoid  Fever,  -  -  -  91 

Tuberculin  In  the  Diagnosis  of  Tuberculosis  in  Cattle,  -  -  92 

Percentage  of  Deaths  in  Chloroform  Administration,  -  -  92 

The  Influence  of  Heredity,  -  -  -  -  -  92 

Unique  Case  of  Intussusception.      -  -  -  -  -  9," 

The  Harvard  Medical  School  Association.  -  -  -  9;-! 

Medico-Chlrurgical  Society,  Trlasgow,         -  .  .  ..  p.*? 

Popular  Prescriptions,         ...---  9^ 

In  Memoriam— William  Colles,  M.D.,  Univ.  Dubl..  F.R.C.S.I.,       -         oj 


"TABLOIDS"  OF  COMPRESSED  DRUGS. 

ThU  form  of  medication  is  htghlv  appreciated  by  the  greater  number  of  tiie  Medtc&l  Profession  for 
the  folliiwin<  reasons:—!.  The  slmrc  ol  tlie  Tabloid"  is  nd.ipted  t  >  the  fornnlion  of  the  throat. 
Manv  unable  to  swallow  pills  can  take  "  Tabloids"  with  the  greati-st  facility.  'J.  The  dose  is  accurateli 
apportioned.  Hni  ca"  be  po-iiivelv  indicated.  3.  The  ••Tabloids  '  are  prepared  with  due  consideration 
as  to  the  jmpoyment  of  each  niediciiment.  Class  A— Soluble  Drugs.  May  be  easily  dis>olved  in  a 
little  water,  and  the  solution  be  tnken  as  a  draught,  or  employed  as  a  gargle,  spray,  or  lotion 
Class  H. -Extracts  and  Powders.  These  "labloids"  miy  be  gulped  \'own  with  a  diaught  of  water. 
Class  C.  -Those  drugs  for  local  etTect.  Can  be  slowly  dissolved  on  the  tnngue  in  llie  suliva.  4  Ihey 
are  made  with  the  very  best  diuss  onlv.  f>.  They  are  dispensed  bv  all  chemists  in  any  quantity  pre- 
scribed, with  minuscript  direction-luhels,  wi'hout  detaining  the  patient  fo:- a  long  time.  6.  Beinijmo>t 
convenient  and  portable,  they  arc  preferred  by  the  profession  for  flllingpocket  or  other  medicine  c<i«e». 

LIST  O**  "TABLOIDS  '  PREPAHED  BY  BUBROUOHS.  WELLCOME  &  CO 


Aconite  Tinet.,  1  mia. 

AloinCj  1,  10  gi. 

Ammon.  B'omide,  6  and  10  gr. 

Amnion.  Chloride,  3,  5,  and  10  gr. 

Ammon.  Chloride  with  Borax. 

Antacid  {Soda  Bicarb.,  Pt  tass.  Bicarb.,  Magnet. 

Curb  ,  aa  'I  gr  ,  Sodii  Chlorid.,  Z  gr) 
•Aloin    Co.   CAloiu.   15  gr.;    Belladonna  Ext., 

I  /8  gr. ;  Strych.,  1/60  gr. ;  Ipecac. ,  1/16  gr.) 
Antifebiin,  2  gr 
Antimony  Tartrate,  1/50  gr. 
Antipyrin.  5  gr 
.\pomorphJiie  M«ir.,  l/oO  gr. 
Aisenious  Acid,  I'lHOand  1/60  gr. 
Atropin  Sulph.,  1  loO  gr. 
Belladonna  Tinct..  1  min. 
Bismuth  Suit  nit..  5  and  10  gr. 
Uiue  Pill.  3  gr. 
Borax,  5  gr 
CKlIeine  Citrate,  2  gr. 
•Calcium  Sulph.,  1  lO  gr 
<-«lo'Tiel,  1  10,  ^,  and  1  gr. 
Capsicum  Tinct.,  1  min. 
•Pascal a  Sagrada  Kxt.,  2  gr. 
•Cascara  Comp.  (Cascnra  Dry  Ext..  1  gr  ;  Eiiony- 

min.  I  gr. ;  Aiix  V.  mii-a  Ext.,  1/16  gr. ;  Hyos- 

cuatims  Dry  Ell.,  1/3  gr. 
•Cathartic  Couip.,  U.  .•<.  F  iEct.  Coloc.  Co.  Pitlv., 

1   1/3  gr.;  Ext.  Jalapce  Pittv.,  1   gr.;  Hyd. 

Snb-chlor.,  1  gr. ;  Cambogiae  Pule  ,  J  gr.) 
Charcoal,  5  gr. 
CblorHlamido,  5  gr. 
Chloral  Hydrate,  5  and  10  gr. 
Cocaine  Mur.,  1  gr. 

Cocaine  with  Potash  and  Borax  (Voice) 
Cretae  Aromat.  cum.  Opio  Pulv.,  6  gr.   (Aromatic 

Confection  with  Opium.) 
Dialy-^ed  Iron.  10  min 
iJigitalis  Tinct..  1  min. 
Digitalin.  l/lOo  gr. 
Uiuretin-^^  Knoll,"  5  gr. 
Pover  Powder.  J  and  5  gr. 
Euonymin  liesin,  1/a  gr. 
Exalgin.  2  gr. 
Kerium  Ke'lactum.  2  gr. 
'iregory  Powder  (see  Khubarb  Comp.  Puiv.'. 
Hvdrarg.  cum.  Creta,  1/3,  {,  and  1  gr. 
Hydrarg.  lod  Rub.,  1/20  gr. 
Hydrarg.  lod  Vir.,  1  S  gr. 
Hydrarg.  Perchlor.,  I'lOO  gr. 
Hydrarg.  Subchlor.  (Calomel).  1/10.  i,  and  1  gr.  • 
•tiydiasiia  Comp.  (ifydraitia  Mur.,  J  gr. ;  Ergo- 
tin,  j  gr.\  Cannabin  Tannate,  i  fr.) 
Ichthyol.  2.j  gr.  ,   . 

Ipecac  and  'ipium.  5  gr.  (Dover  Powder.; 
Ipecac.  Powder,  1/10  and  5  gr.      ' 
Iron  and  Arsenic  Comp.  {(iuinine  Biiulph.,  1  gr.; 

Iron  Hypophnt  .   2  gr. ;  ArUnic,  Strychnine 

(sulph..  aa  1,M  pr  ) 
Iron  and  Quinine  Cit..  3  gr. 
•Laxative  Vegetable  f7to  Podol]-h..  Ext  Hyoscy., 

Ext    Tarax .  ao  1/4  gr. ;   Ext.  Coloc.  Pu.lv  , 

1  gr. ;  Jalapce  Pulv.,  Kes.  Leptand.,  aa  1/2  gr. 

01.  Menth  Pip) 
Lithia  Carbonate,  2  gr. 


I  ithia  Co.  (|ir  Lane's  foimula.) 

Manganese  L)io.\ide.  2  gr. 

Morphine  Sulph..;l/liMi,  1  20,  and  1/S  gr. 

Kaso- pharyngeal  (Sodiura  Chlorid.,  Borax.  Borxr 

Acid,    Binzoic,  Acid,    Menthol,    Thynwl,    01. 

GauUheria,  Cocaine  Mur.). 
Nitroglycerine,  1/100  gr.  (see  also  Trinitrine.) 
Nux  Vomica  Tinct..  1  min. 
Opium  Tinct.  (Laudanum),  2  min. 
Papain.  2  gr.  (Dr.  Kinkier  <t  Co.) 
Pepsin  (Fairchild). 
Pepsin,  Sacchaiated,  5  gr. 
Peptonic  (.Pepsin,   Zymine,  Lacto-pkoiph.  Limt, 

p.  ay.). 
Phenaceiin.  5  gr.  '    i 
Pilocarpin  Mur.,  J/ 20  gr 
Podophyllin  Resin,  ^  gr. 
Potass  Kicarli..  0  gr. 
Potass  Bromide,  o  and  10  gr. 
Potais  Chlorate,  6  gr. 
Potass  Chlorate  with  Borax. 
Poia--s  lodde,  5  gr. 
Potash  Nit.  (.Sal  Prunella).  5  gr. 
Potass  Fermangannte,  1  and  2  gr. 
Quinine,  1/10,  and  ^  gr. 
"Quinine  (Soluble),  1,  2,  3,  and  5  gr. 
Reduced  Iron,  2  gr, 
lihuliarb.  3  gr. 
•Rhubarb    Comp.  (fill),  3  gr.   (ffAei   Pulv.,  \i; 

Aloe  Sac.    Pulv,    1;    Saponis    Palv.,    «/8, 

Myrrhce  Pulv.  5/8  parts:  01.  Henth  lip.) 
Rhubarb  Comp.  Pulv.  (Gregory  Powd).  6  gr. 
Rhubarb  and  Soda,  5  gr.  (Rhei.,  3 ;  Sodce  Bicarb., 

2;  Zingiber,  J  parts) 
.Saccharin,  i  gr. 
Salicin,  5  gr. 
Salol,  5  gi- 
.Santonin,  'j  gr. 
Soda  Bicarbonate,  6  gr. 
Soda  Mint    or    Neutralising    "Tabloids"    (Sx/a 

Bicarb.,    4   gr.;   Animon.    Carb ,  J   gr. ;    01. 

.Wenth  Pip.   J  .err.) 
Soda  .<^alicylate.  3  and  6  gr. 
Mroi>hanthu8  (2  minims  of  Tinct.  in  each). 
Sulphur  Comp.  (Sv-lph.  Pr<£cip  ,  6  gr  ;    Potatt 

Bitart.,  1  gr. 
Tannin.  2^  gr. 
Test  Tabloids  (Kehling's). 
Tliirst  (EtTervescent). 
Ton  c   (^oinp.    (Iron  Pyrophos.,  1   gr  ;    Quinir^e 

Hisulph.,  1  gr.;  Strychnine  Sulph,  1/100  gr.) 
Trinitrine  (Nitro-glycthine)  1/100 and  1/60 gr. 
Trinitrine  and  AmylNitrite. 
Trinitrine  Comp.  (Trijiilrine,  1/100 gr.;  NitriitoJ 

Aiiiyl,  J  gr.;  Capsicum,  1/50  gr.;  Mtnthol, 

1/50  gr) 
Urethane,  5  gr. 

Voice  (Potash,  Borax  and  Cocaine). 
Warburg  Tincture,  3^  mina.  in  each. 
Zinc  Sulphate,  1  gn.'  ' 
Zinc  Sulpho-carbplf  te,  2  gr. 
7ymine  (PancreatinV 
Zymine   Comp.    '•  Tabloids "    (Zymine,    3    gr. : 

Bismuth.  Subfi't.,  2  gr  ;  Powd.  Ipecac.,  1/10 

gr.)  '   ■  ■■   ■ 


Those  "  Tabloids  "  marked  with  an  asterisk  are  coated  with  a  perfectly  soluble  coating  of  pure  white 
lugar.    These  coated  "Tabloids"  will  only  be  disabused  bv  chemists  when  spkciallt  indicated 


JV  THP  puvmcia-^ 


BUEROUGHS,  WELLCOME,  &  CO.,  Snow  Hill  Buildings,  London.  B.C. 

Will  be  hapjji/  to  send  Price  Littt  and  Samplet  of  Soluble  "  TABLOIDS"  lo 
Medical  Men  £ust  fru  oh  rei[uest. 


THE    DUBLIN    JOURNAL 

OF 

MEDICAL    SCIENCE. 


JULY  1,  1892. 


PART  I. 

ORIGINAL  COMMUNICATIONS. 


Art.  I. —  Clinical  Observations  on  Pleural  Effusion  with  Displace- 
ment of  the  Hearth  By  W.  Langford  Symes,  L.R.C.P.I.,  &c., 
Kiltegan,  Co.  Wicklow. 

The  subject  which  I  wish  to  introduce  is  one,  I  think,  well 
deserving  of  investigation,  and  I  trust  a  brief  review  of  it  will 
not  be  uninteresting,  inasmuch  as  displacement  of  the  heart  in 
effusions  of  either  pleural  sac  is  sometimes  the  source  of  intense 
anxiety  to  the  clinical  physician,  occasionally  of  sudden  death  to 
the  patient,  and  ever  of  great  interest  to  the  physiologist.  It  is 
well  illustrated  by  the  following  case,  which  is  no  way  more 
remarkable  than  many  others,  except  perhaps  in  its  being  allowed 
to  run  so  long  without  being  tapped : — 

Case. — A  healthy  man  of  twenty  was  suddenly  seized  with  severe 
rigors,  which  liisted  for  five  hours.  Two  hours  after  the  shivering  ceased 
I  found  his  T.  102-4°,  P.  120,  Resp.  28;  he  was  very  hot  and  flushed 
on  the  left  cheek,  severe  pain  shooting  through  his  left  lung,  unable  to 
draw  a  full  breath,  and  feeling  very  sick  and  faint.  On  examining  his 
chest  I  found  slight  dulness  and  diminution  of  free  vesicular  breathing 
over  the  lower  lobe  of  the  left  lung  behind,  with  peculiar  "  cogged- 
wheel"  or  interrupted  respiration.  There  was  loud  puerile  breathing  all 
over  the  right  lung,  but  otherwise  the  chest  was  healtliy.  He  was  ordered 
a  diaphoretic  mixture  of  tinct.  aconit. ;  spt.  aeth.  nit. ;  with  liquor  ani- 

*  The  substance  of  this  paper  was  read  before  the  Birkenhead  Medical  Society, 
Session  1887-88. 

VOL.  XCIV. NO,  247,  THIRD  SERIE8.  B 


2  Pleriral  Effusion  xoith   Displacement  of  the  Heart. 

moniae  acetatis  every  two  hours,  and  fever  diet,  while  linseed  poultices 
were  continually  applied. 

Next  morning  his  pulse  had  fallen  to  100,  but  T.  and  Resp.  still  the 
same.  On  examining  the  chest  the  dulness  was  more  marked,  vocal 
resonance,  and  all  respiratory  sounds  completely  lost  over  left  base ;  the 
puerile  breathing  in  the  right  lung  very  loud  and  distinct — in  fact,  all 
the  usual  signs  of  effusion.  The  following  day  (3rd)  I  was  suddenly 
called  to  see  him,  as  he  had  fainted  on  getting  out  of  bed,  but  was  quite 
restored  when  I  arrived.  The  effusion  now  steadily  increased,  and  on 
the  4th  day  his  condition  was  as  follows  : — Temp.  99"8°,  P.  100, 
Resp.  24.  Absolute  dulness  with  resistance,  and  complete  loss  of  vocal 
phenomena  and  breath  sounds  over  the  left  base  as  high  as  the  spine  of 
the  scapula,  crossing  in  front  to  the  level  of  the  5th  rib.  There  was  no 
apex  beat  to  be  seen  or  felt  anywhere  on  either  side  of  the  chest,  but  the 
heart  was  under  the  sternum,  the  first  sound  reaching  its  maximum 
intensity  at  the  base  of  the  ensiform  cartilage.  He  complained  of  great 
pain  in  the  left  shoulder,  a  troublesome  dry  cough  and  slight  dyspnoea, 
these  symptoms  being  the  chief  ones  throughout  the  attack.  He  was 
ordered  a  mixture  of — 

I^.  Potass,  acetatis,  gr.  8  ; 
Tinct.  digitalis,  m  8 ; 
Spt.  juniperi,  Ttl  15; 
Spt.  3eth.  nitrosi,  m  20 ; 
Liq.  ammon.  acetatis,  3i ; 
Decoct,  scoparii,  gss — every  4th  hour ; 
and  iodine  was  applied  to  the  lung. 

On  the  7th  day  his  T.  was  101°,  P.  120,  R.  24.  He  lay  on  his 
back,  inclining  towards  the  right  side,  saying  it  was  impossible  to  turn 
on  the  left  owing  to  the  pain  in  the  shoulder,  dyspnoea  and  anxiety. 

By  the  8th  day  the  fluid  had  reached  the  2nd  rib,  dulness  extending 
high  up  into  axilla,  crossing  midsternum  at  the  5th  rib ;  notwithstanding, 
the  urine  had  become  very  copious,  and  he  had  perspired  profusely. 
Decubitus  still  the  same ;  intercostal  spaces  depressed  and  not  yielding  to 
the  pressure  of  the  fluid.  The  heart  was  completely  dislocated  from  the 
left  side,  and,  protruding  from  beneath  the  right  border  of  the  sternum, 
pulsated  between  the  4th  and  5th  right  costal  cartilages.  On  the  I2th 
day  the  chest  presented  a  most  remarkable  condition.  The  effusion 
increasing,  had  encroached  still  more  on  the  right  side,  pushing  up  the 
left  lung  under  the  1st  rib  and  compressing  it  against  the  spine — the  only 
resonant  portion  being  that  above  the  2nd  rib,  which  elicited  on  percussion 
the  peculiar  tympanitic  note  described  by  Skoda  and  Hudson.  This  note 
contrasted  remarkably  with  the  full,  healthy,  resonant  sound  yielded  by 
the  right  lung,  and  the  absolute  "femoral"  dulness  over  the  fluid 
immediately  beneath.     The  heart  was  still  further  displaced  to  the  right, 


By  Mr.  W.  Langford  Symes.  3 

boating  at  a  point  one  inch  above  and  slightly  internal  to  the  right 
nipple.  The  first  sound,  however,  was  loudest  over  body  of  the  left 
ventricle  in  the  sternal  end  of  the  4th  interspace.  From  this  date  signs 
of  absorption  gradually  developed,  vocal  phenomena  returning  with 
aegophony  and  feeble  respiration  until,  on  the  18th  day  (Fig,  1),  the 
fluid  had  receded  to  the  level  of  the  4th  rib,  allowing  the  heart  to  return 
beneath  the  sternum  and  the  upper  lobe  of  the  left  lung  to  once  more 
expand  during  inspiration ;  over  this  area,  above  the  4th  rib,  the  .Skodaic 
tympany  had  disappeared,  and  a  peculiar  fine  crackling  crepitation  was 
heard  at  the  end  of  each  inspiration  precisely  similar  to  Laennec's  first 
stage  of  pneumonia.  This  I  attributed  to  the  air  for  the  first  time  re- 
entering the  smaller  bronchi  and  alveoli  of  the  upper  lobe  and  forcibly 
separating  their  w^alls,  which  had  been  so  long  collapsed  from  pressure  of 
the  fluid. 

On  the  22nd  day,  T.  98°,  P.  76,  dulness  still  up  to  4th  rib,  heart 
beating  at  5th  left  cartilage ;  respiration  easy,  and  he  lies  chiefly  on  the 
left  side. 

The  remaining  serum  now  became  rapidly  absorbed,  and  he  quickly 
regained  his  strength.  He  was  ordered  the  citrate  of  iron  and  ammonia, 
with  counter-irritation  to  the  lung.  A  fortnight  later  (32nd  day)  all 
effusion  had  disappeared,  and  he  was  quite  well  and  walking  about. 
The  heart  once  more  pulsated  in  its  normal  position,  but  seemed  more 
exposed  towards  the  base  owing  to  the  incomplete  expansion  of  the  lung. 
A  cardio-pleuritic  friction  sound  was  now  heard  over  the  3rd  rib. 

A  week  later  (41st  day)  I  stripped  him  and  made  a  careful  examination 
of  his  chest,  finding  distinct  evidence  of  commencing  hypertrophy  of  the 
right  ventricle,  and  commencing  emphysema  of  the  right  lung.  The  left 
side  of  the  chest  was  2^  inches  smaller  than  the  right  at  3rd  rib,  and 
measured  2  inches  ^ess  at  the  level  of  the  5th  rib.  There  was  deficient 
expansion  of  the  left  lung,  evidenced  by  inspection,  but  particularly 
when — standing  behind  him — the  sides  of  the  chest  were  grasped  by 
the  hands — the  left  feeling  quite  thin  like  a  book,  whereas  the  right  was 
hyper-distended,  and  felt  as  if  one  was  endeavouring  to  grasp  a  football. 

He  was  ordered  syrupus  ferri  iodidi,  and  a  month  later  was  perfectly 
well,  with  the  exception  of  a  contracted  left  side. 

The  gradual  displacement  of  the  heart  in  effusions  of  the  left 
pleura  affords  the  most  interesting  subject  for  observation  and 
thought  at  the  bedside,  as  literature  on  this  point  is  singularly 
wanting.  Many  authors  do  not  even  allude  to  it,  others  give 
it  but  a  passing  notice ;  while  those  who  attach  most  importance 
to    it    are  Dr.  Mitchell  Bnice"  and  the  late   Drs.  Stokes''  and 

'  Quain's  Dictionary  of  Medicine.     Art.  Displacement  of  the  Heart. 
*>  Diseases  of  Chest.     1837.     Pp.  449  et  seq. 


4 


Pleural  Effusion  with  Displacement  of  the  Heart. 


Townsend.*  Professor  Finny  **  has,  however,  contributed  by  far 
the  most  valuable  and  instructive  paper  on  the  clinical  aspects  of 
this  subject. 

Fig.  1. 


"VVe  observe,  first  (Fig.  1),  that  the  apex  strikes  in  a  position 
about  midway  between  its  normal  site  and  the  base  of  the  xiphoid 
cartilage.  As  the  distension  goes  on  the  heart  "buries"  itself 
under  the  sternum,  and  its  impulse  is  for  a  time  lost.  It  pre- 
sentlv  emerges  from  beneath  its  right  border,  pulsating  vigorously 
under  the  5th  costal  cartilage,  and  as  the  effusion  increases  it  is 
dislocated  in  a  direction  upwards  and  to  the  right.  These  facts 
were  observed  by  Stokes  as  early  as  1837.  It  may  now  be  discovered 
beatinw  in  the  right  nipple  line  as  high  as  the  3rd  interspace,  or, 
as  in  an  extreme  case  which  I  once  witnessed,  may  even  pulsate 
beneath  the  anterior  fold  of  the  right  axilla.  From  this  abnormal 
site  it  gradually  returns  as  the  effusion  becomes  absorbed,  but  on 
close  observation  will  be  found  to  pass  back  on  a  j)lane  from  ^  to 
1  inch  higher  than  its  original  course,  and  thus  regain  its  normal 
position  bv  a  shorter  and  more  direct  route  across  the  front  of 
the  thorax.     Now  two  factors,  I  believe,  exist  which  combine  to 

'  Cyclopjedia  of  Practical  Medicine  (Forbes).     Art.  Displacement  of  Heart, 
■i  Tiansactions  of  Academy  of  Medicine  in  Ireland.     Vol.  I.     1883. 


By  Mk.  W.  Langford  Symes.  5 

produce  this  peculiar  alteration  in  the  heart's  path.  The  one  is 
apparent,  the  other  real,  and  both  are  dependent  upon  the  imper- 
fect expansion  of  the  lung.  When  the  effusion  becomes  rapidly 
absorbed,  and  the  lung  cannot  with  equal  rapidity  burst  its 
adhesions  and  distend  its  thickened  and  hypertrophied  pleura, 
the  left  side  commences  to  fall  in,  and  the  ribs  become  approxi- 
mated. Each  rib  will  now  be  found  to  occupy  a  more  inferior 
position  than  it  did  before  with  reference  to  the  thoracic  viscera, 
so  what  is  apparently  a  superior  course  taken  by  the  heart 
on  its  return  to  the  left  side  may  be  in  reality  a  depression 
and  approximation  of  the  ribs,  making  it  appear  to  return  on 
a  higher  plane.  The  other  factor  (and  this  the  most  potent, 
operating  before  the  side  falls  in,  and  while  the  heart  is  still  to  the 
right  of  the  mesian  line)  is  a  true  change  in  the  direction  of  the 
heart's  path,  by  which  it  can  with  the  greatest  rapidity  again 
reach  the  left  side.  It  is,  in  fact,  draA\Ti  directly  into  the  potential 
vacuum  caused  by  the  rapid  recession  of  the  fluid.  These  I 
believe  to  be  the  true  explanations  of  this  interesting  phenomenon, 
which,  if  the  initial  course  taken  by  the  heart  has  been  carefully 
noted,  cannot  but  strike  the  most  casual  observer.  Again,  this 
superior  course  of  the  heart  across  the  chest  being,  as  we  have 
seen,  directly  dependent  upon  the  non-expansion  of  the  lung,  may 
be  found  to  be  proportional  to  it,  an  early  clinical  evidence  of  it, 
and  a  measure  of  the  diminution  in  its  volume — provided,  of  course, 
it  be  not  bound  by  adhesions. 

The  lung  may,  however,  eventually  expand  to  its  former  size, 
and  the  heart  resume  its  normal  position ;  but  such  conditions  are 
rare  after  large  or  protracted  effusions.  Moreover,  if  this  expan- 
sion be  complete  and  truly  proportional  to  the  absorption  of  the 
fluid,  the  heart  will  probably  be  found  to  return  by  its  original 
course.  It  is  evident  that  the  displacement  under  consideration 
occurring,  as  it  does,  concurrently  with  the  absorption,  cannot  be 
due  at  this  early  stage  to  the  contraction  of  any  adhesions  between 
the  pleura  and  pericardium,  which  have,  in  fact,  not  been  in  con- 
tact. For  even  in  the  later  stages  of  pulmonary  cirrhosis  such 
upward  displacements  of  the  heart  are,  as  has  been  pointed  out 
by  Dr.  Mitchell  Bruce,  more  atmospheric  than  cicatricial  in 
origin. 

Equally  interesting  points  in  connection  with  this  subject  are 
the  mechanism  by  which  the  displacement  to  the  right  is  pro- 
duced, and  the  anatomical  relations  of  the  heart  whicli  admit  of 


6  Pleural  Effusion  with  Displacement  of  the  Heart. 

its  production ;  and  a  glance  at  these  rough  diagrams  may  help 
to  elucidate  my  description.  We  must  remember  that  the 
heart  is  chiefly  attached  by  its  superior  and  right  borders,  at 
the  right  and  upper  extremity  of  the  long  cardiac  axis  (Bruce) 
corresponding  for  all  clinical  purposes  to  a  point  about  midway 
between  the  3rd  costal  cartilages,  and  that  it  is  lying  loosely  in 
the  pericardium,  suspended,  as  it  were,  obliquely  from  this  fixed 
point  by  the  great  vessels  and  deep  process  of  the  cervical  fascia. 
It  may  thus  be  regarded  as  being  normally  displaced  to  the  left, 
the  attachments  being  mainly  in  the  mesian  line,  and  as  being 
capable  of  greater  movement  to  the  right  than  towards  the  left. 

From  these  facts  it  follows  that  when  pressure  is  exerted  on 
either  side  of  the  pericardium,  sufficient  to  displace  the  heart 
(Fig.  5),  its  apex  moves  somewhat  in  the  arc  of  a  circle  whose 
centre  is  this  fixed  point  and  radius,  the  long  cardiac  axis,  cutting 
the  chest  wall  at  the  base  of  the  xiphoid  cartilage,  the  5th  inter- 
costal spaces  on  either  side  in  the  right  and  left  parasternal  lines, 
and  a  point  about  1  inch  outside  each  nipple,  whereas  the  base 
may  remain  comparatively  stationary  unless  the  distensile  force 
be  so  great  as  to  displace  the  entire  contents  of  the  mediastina. 
The  more  movable  heart  is,  however,  first  acted  upon.  Hence,  in 
any  given  case,  if  we  find  the  apex  outside  this  circle,  we  may 
conclude  that  the  basic  attachments  of  the  heart  have  been  severely 
compressed,  their  relations  altered,  and  that  the  case  is  fraught 
with  extreme  danger.  This  I  observed  in  the  foregoing  case,  and 
accounts  for  the  impulse  being  above  the  right  nipple  on  the  12th 
day  at  least  1  inch  higher  than  the  normal  level  of  cardiac  dulness. 
But  besides  this  revolution  round  its  basic  attachments,  rotation 
on  its  long  axis  must  also  occur,  with  the  result  that,  if  to  the 
right,  the  left  ventricle  and  auricle  become  anterior,  while  the 
right  ventricle  and  right  auricle  are  rotated  into  a  posterior  posi- 
tion, and  lie  at  the  back  of  the  heart  on  the  front  wall  of  the 
posterior  mediastinum. 

Moreover,  we  find  this  rotation  is,  in  a  minor  degree,  one  of  the 
normal  visible  movements  of  the  heart,^'  for,  "  during  each  suc- 
ceeding systole  the  heart  is  seen  to  twist  slightly  on  its  long  axis, 
so  that  while  the  base  is  fixed  the  apex  moves  from  the  left  and 
behind  towards  the  front  and  right,  displaying  more  of  the  left 
ventricle ;  the  cycle  being  completed  during  the  diastole  by  the 
flattening  of  the  ventricles,  the  heart  turning  back  towards  the 
'  Foster.     Text-book  of  Physiology. 


By  Mr.  W.  Langford  Symes.  7 

left."  Again,  these  are  the  positions  in  which  the  cavities  are 
most  frequently  found  when  it  is  congenitally  displaced  to  the 
right,"*  the  auricles  and  ventricles  occupying  positions  exactly  the 
contrary  of  their  relative  ones  on  the  left  side,  the  apex  pointing 
downwards  and  to  the  right. 

The  reverse  of  course  takes  place  in  "  sinistrocardia  "  from  right 
effusions,  but  displacement  is  more  limited  here  from  the  oblique 
suspension  of  the  organ  by  nature,  and  rotation  towards  the  left 
having  thereby  already  occurred.  Such  rotation  during  displace- 
ment I  believe  accurately  accounts  for  two  peculiar  signs  existing 
in  this  case — viz.,  more  vigorous  impulse  and  louder  first  sound  than 
when  the  heart  was  in  its  normal  site,  due,  doubtless,  to  the 
anterior  position  of  the  left  ventricle. 

I  can  find  no  allusion  to  these  signs  as  clinical  evidences  of 
rotation  in  any  work  on  the  chest,  though  they  are  very  striking. 
Dr.  Frederick  Roberts,^  however,  attributes  the  impulse  to  the 
right  ventricle.  In  other  respects  the  sounds  are  normal.  With 
Dr.  Douglas  Powell's"  opinion  that  the  axis  of  the  heart  can  never 
diverge  beyond  the  vertical  line  or  only  to  a  very  slight  extent, 
and  that  the  apex  does  not  point  to  the  right,  my  observations  on 
these  cases  do  not  coincide.  The  chief  resistance  to  this  displace- 
ment is  that  offered  by  the  right  lung  and  right  wall  of  the 
mediastinum,  but  these  cannot  be  at  all  considei'able,  since  we 
have  seen  a  slight  amount  of  effusion  is  sufficient  to  overcome 
them,  and  they  yield  long  before  the  intercostal  muscles  or 
diaphragm. 

When,  however,  the  right  lung  has  become  indurated  from  dis- 
ease, or  its  pleura  thickened  or  adherent,  it  is  clear  that  displace- 
ment cannot  occur  easily,  and  there  arises  in  these  cases  a  fertile 
source  of  danger  from  its  compression  against  these  unyielding- 
structures. 

Under  these  conditions  the  respiration  will  be  found  very  much 
distressed  and  out  of  proportion  to  the  extent  of  the  disease,  per  se. 

The  left  pulmonary  vessels  would  seem  to  have  no  restraining 
influence,  for  when  we  consider  that  the  left  lung  has  ere  this 
been  compressed  against  the  spine  and  mediastinum,  these  vessels 
are  thereby  relaxed  and  rendered  useless  for  the  time  being. 

•  Breschet.  Memoire  aur  I'Ectopie  du  Cceur.  Repertoire  G^n^ral  d'Anatoinie. 
Vol.  II. 

''  Theory  and  Practice  of  Medicine. 

"  Disease  of  Lungs. 


8  Pleural  Effusion  with  Displacement  of  the  Heart. 

The  other  dangers  of  dexiocardia  must  not  be  forgotten.  They 
are  mainly  due  to  twisting  of  the  venae  cavae,  leading  to  thrombosis 
or  occlusion  of  these  thin  vessels,  and  also  I  think  the  curvature 
in  the  right  branch  of  the  pulmonary  artery,  which,  in  this  posi- 
tion of  the  heart,  must  be  extreme,  and  on  which  the  aeration  of 
the  blood  now  almost  entirely  depends. 

Regarding  the  peculiar  form  of  decubitus  assumed  in  this  case 
(half  right  and  half  dorsal),  it  is  rare  to  see  a  patient  lie  so  much 
on  the  healthy  lung  when  such  a  large  effusion  exists  in  the 
opposite  pleural  sac,  and  no  explanation,  as  far  as  I  know,  has 
ever  been  given  for  this  strange  phenomenon,  although  repeatedly 
observed  in  severe  cases.*  Now,  careful  clinical  observation  on 
this  point  has  convinced  me  that — (1st)  This  posture  is  indicative 
of  an  effusion  of  fluid  of  exceedingly  high  tension  into  the  opposite 
pleura,  not  necessarily  an  enormous  one ;  and  (2ndly)  that  by  this 
position  its  tension  is  lessened. 

So  much  indeed  has  been  written  on  this  subject  that  one  hesi- 
tates to  enter  on  it.  However,  I  will  mainly  allude  to  his  three 
symptoms. 

Their  explanation  is,  I  believe,  the  following.  When  he  lay 
over  on  the  left  side,  the  abdominal  viscera  gravitated  to  beneath 
the  left  ala  of  the  diaphragm  (which  was  distended  by  the  effusion), 
exerting  pressure  on  its  under-surface,  and  probably  causing  his 
shoulder-pain  through  the  cervical  connections  of  the  phrenic 
nerve.  This  upward  pressure  likewise  increased  the  tension  of  the 
fuid,  and,  tending  to  further  displace  the  heart,  produced  cardiac 
dyspnoea  and  "praecordial  anxiety,"  compelling  him  in  a  few 
minutes  to  turn  on  the  other  side.  Similarly,  contact  of  the  side 
with  the  bed  when  lain  upon  would  have  the  same  effect.  Undue 
stress  has  been  laid  upon  the  so-called  "  weight "  of  the  fluid  on 
the  mediastinum  preventing  decubitus  on  the  sound  side,  as 
originally  stated  by  Le  Dran ;  for  potent  as  this  is  in  cases  of 
empyo-pneumothorax  where  atmospheric  pressure  comes  into  play, 
it  is  impossible  to  conceive  its  action  in  simple  effusion  into  the 
pleura,  which  is  a  shut  sac,  closed  to  the  external  air,  where  the 

'  "  Thus  Isenflamm  relates  a  case  where  a  patient  presenting  all  the  usual  signs  of 
empyema  lay  generally  on  the  right  side,  which,  for  this  reason,  was  supposed  to  be 
the  seat  of  the  disease ;  accordingly  the  operation  was  performed,  but  no  pus  was 
found.  The  patient  died,  and  on  dissection  it  was  discovered  that  the  left  side  was 
the  seat  of  the  empyema.  Morgagni  relates  a  case  of  this  kind  on  the  authority  of 
Valsalva ;  and  M.  Baffos  records  another  instance."  Cf.  Stokes.  Diseases  of  the 
Chest.     1837. 


By  Mr.  W.  Langford  Symes.  9 

pressure  of  the  fluid  is  uniform  in  every  direction,  and  incapable 
of  increase  by  gravitation.  Moreover,  this  is  borne  out  by  the 
experiments  of  M.  Richerand  on  hydrothorax  artificially  produced. 
Now  it  is  the  tension  of  the  fluid,  I  believe,  which  causes  most  of 
the  trouble,  and  this  appears  to  be  distinctly  lessened  by  lying  on 
the  sound  side,  which,  by  removing  the  abdominal  viscera,  allows 
the  diaphragm  to  "  bulge  "  downwards  and  the  capacity  of  the 
affected  side  to  be  proportionally  increased. 

All  possible  freedom  must,  however,  be  given  to  the  healthy 
lung,  as  pointed  out  by  Richerand,^  Townsend,  and  Chomel ;  ^  but 
in  the  foregoing  case  the  distress  from  increased  tension  so  far 
exceeded  that  from  embarrassed  respiration  that  the  relief  of  the 
former  became  an  urgent  necessity,  while  the  free  expansion  of 
the  right  lung  was  of  secondary  importance  and  had  to  be 
performed  under  difficulties. 

Hence,  it  is  clear  that  conditions  indicating  distress  on  change 
of  posture  (dyspncea,  pain,  anxiety),  whether  arising  from  increase 
in  the  tension  of  the  fluid — lying  on  the  affected  side — or  inter- 
ference with  respiration — lying  on  the  sound  side — are  exclusively 
produced  by  influences  operating  outside  the  thorax  (position  of 
abdominal  viscera,  conditions  preventing  free  descent  of  diaphragm 
or  elevation  of  the  ribs) ;  and  hence  we  also  find  that  the  form  of 
decubitus  chosen  by  the  patient  is  that  in  which  the  tension  of 
the  fluid  is  least,  and  in  which,  at  the  same  time,  the  healthy  lung 
has  least  interference  with  its  free  expansion.  Thus,  this  patient 
lay  on  his  right  side  as  far  as  his  abdomen  and  legs  w^ere  concerned, 
but,  in  order  to  free  the  right  lung  as  much  as  possible,  endeavoured 
to  rotate  his  thorax  into  a  dorsal  position. 

Further  proof  of  the  influence  of  tension  in  determining 
decubitus  is  afforded  by  comparing  the  symptoms  during  the 
accumulation  of  the  fluid  when  its  tension  is  at  its  maximum  and 
organs  are  being  displaced,  with  those  during  absorption  when  the 
fluid  is  receding,  and  its  tension  reduced  to  a  minimum,  the  level 
of  the  effusion  being  in  both  cases  the  same. 

Let  us  take  the  4th  rib.  We  find  on  the  7th  day,  T.  101°, 
P.  120,  R.  24.  The  effusion,  rapidly  increasing,  has  reached  this 
level :  he  has  had  two  attacks  of  fainting  within  the  last  3  days 
on  very  slight  exertion ;  the  heart  is  on  the  right  of  the  mesiau 
line ;  his  decubitus  is  half  right  and  half  dorsal,  and  in  this  posi- 

*  Cycl.  Practical  Medicine.     Art  Empyema. 
"  Dictionaire  de  M^decine.     Art.  Pleurisie. 


10  Pleural  Effunon  ivith  Displacement  of  the  Heart. 

tion  he  is  compelled  to  remain,  every  attempt  to  turn  on  the 
affected  side  being  followed  by  shoulder-pain,  dyspnoea,  and 
anxiety.  By  the  22nd  day  the  fluid  has  again  receded  to  this 
level :  T.  98°,  P.  76 ;  his  respiration  is  easy,  and  he  can  lie  and 
sleep  in  any  position  on  either  side,  but  jyrefers  the  left,  as  this 
has  now  become  the  most  comfortable.  The  heart  pulsates  under 
the  5th  left  cartilage,  and  he  has  only  one  recurrence  of  fainting 
daring  the  last  three  days. 

Now,  the  differences  in  the  symptoms  on  the  above  dates  can,  I 
think,  be  due  only  to  alterations  in  the  tension  of  the  fluid,  its 
level  being  identical  in  each  case.  For  while  it  is  e\adent  that 
fluid  cannot  accumulate  in  the  pleura  until  its  tension  exceeds 
the  pressure  of  the  atmosphere,  it  is  likewise  true  that  during 
absorption  its  tension  is  so  far  below  this  standard  that  the  pres- 
sure in  the  affected  side  actually  becomes  negative,  and  if  the 
lung  cannot  expand,  deformity  necessarily  results.  Furthermore, 
1  believe  that  the  more  rapid  the  effusion,  the  higher  will  its 
tension  be  found,  and  the  greater  the  distress  produced  by  it; 
and,  vice  versa,  that  the  more  gradual  and  "  quiet "  the  effusion 
the  less  is  its  tension  and  the  milder  are  the  accompanying  symp- 
toms. 

Again,  since  (1)  Tension  and  (2)  Compensation  are  the  two 
conditions  which  determine  a  simple  or  serious  case,  and  on  which 
paracentesis  will  frequently  depend,  the  symptoms  indicating  high 
tension  in  the  fluid  are  of  great  clinical  value.  They  will  be 
found  to  be  : — 

1.  Decubitus  on  the  healthy  lung,  or  difficulty  in  lying  on  the 
effusion. 

2.  Fixed  or  peculiar  decubitus  :  where  the  patient  is  constrained 
to  lie  in  one  position. 

3.  Dyspncea  out  of  proportion  to  the  amount  of  disease. 

4.  Where  upward  or  lateral  pressure  on  the  affected  side  pro- 
duces distress  or  dyspnoea. 

The  extent  of  dulness,  estimated  quantity  of  fluid,  or  displace- 
ment of  the  heart  are  no  safe  guides  either  in  prognosis  or  treat- 
ment. 

In  support  of  these  views,  which,  as  far  as  I  know,  have  not 
been  hitherto  advanced,  it  is  satisfactory  to  notice  that,  while 
they  clear  up  the  difficulties  heretofore  enveloping  this  subject, 
and  reconcile  the  conflicting  statements  of  must  accurate  observers 


By  Mr.  W.  Langford  Symes.  11 

(each  in  itself  correct),^  they  also  explain  the  anomalous  clinical 
facts  that  we  sometimes  see  copious  effusions  in  persons  free  from 
constitutional  disturbance  or  local  distress  who  can  lie  equally 
well  on  both  sides ;  that  some  patients  lie  on  the  healthy  and 
others  on  the  affected  side ;  that  the  same  patient  lies  at  different 
periods  on  each  side ;  and  finally  they  prove  by  their  analogy  with 
the  notes  of  Dr.  Finny's  case  that  when  the  heart  cannot  be  dis- 
located owing  to  the  resistance  of  structures  indurated  by  disease, 
any  excessive  elevation  in  the  tension  of  the  fluid  is  a  potent 
cause  of  sudden  death. 

Of  displacement  of  the  heart  to  the  left  there  seems  to  be  less 
clinical  experience.  In  a  case  recorded  by  Dr.  Hayes  ^  of  right 
empyema  reaching  to  within  three  inches  of  the  clavicle,  "  the 
cardiac  apex  was  considerably  displaced  to  the  left,  and  the  heart 
sounds  were  weak,"  but  there  was  no  murmur — the  feebleness 
being  possibly  dependent  upon  the  complete  seclusion  of  the  left 
ventricle  from  left  rotation.  In  these  cases  of  sinistrocardia  the 
risks  of  sudden  death  would  seem  to  be  greater  than  those  attend- 
ing right  displacement,  arising  from  pressure  of  the  fluid  on  the 
thin  walls  of  the  vense  cavae  and  right  auricle — which  must  be 
extreme  before  the  entire  heart  will  be  dislocated  to  the  left — 
torsion  of  the  cava;  as  a  natural  consequence,  and  the  possibility 
of  a  dangerous  increase  in  the  natural  curve  of  the  aortic  arch. 

Since  the  heart  may  be  regarded  as  being  normally  displaced  to 
the  left  in  health,  its  axis  forming  with  the  mesian  line  an  angle 
of  about  40°,  it  is  probable  that  few  dangers  attend  dislocations  to 
the  right  of  an  ^  qual  extent,  but  this  point  exceeded  they  are 
much  increased.  As  bearing  on  this,  syncope  occurred  in  the 
foregoing  case  but  once  while  the  heart  was  within  these  limits 
and  t/u^ee  times  afterwards. 

One  other  point  of  great  interest  must  be  noticed — viz.,  the 
pathology  of  the  "  tympanitic  "  (?)  note  under  the  clavicle. 

From  the  time  when  Skoda,  in  1839,  published  his  theory-  of 

*  Thus  Bichat  and  Roux  stated  that  pressure  upwards  on  the  side  corresponding  to 
the  effusion  caused  extreme  distress  ;  while  Townsend  and  Chomel  found  the  very 
reverse  to  be  the  case,  upward  pressure  on  the  sound  side  being  intolerable,  while 
that  on  the  affected  side  was  borne  with  impunity — the  forn\er  being  correct  in  severe 
cases  with  high  tension  and  peculiar  deculiitus,  and  the  latter  true  in  moderate 
effusions  or  during  stage  of  absorption  where  the  tension  is  low  and  patient  lies  on  the 
affected  side,  and  where  upward  pressure  on  the  sound  side  will  impede  the  action  of 
the  diaphragm. 

*•  Transact.  Acad,  Medicine  in  Ireland.     Vol.  I.     1883. 


12  Pleural  Effusion  with  Displacement  of  the  Heart. 

percussion  sounds,  difference  of  opinion  has  existed  as  to  its 
nomenclature  and  significance.  "  Le  bruit  SJcodique"  of  the 
French,  or  our  "  Skodaic  resonance,"  is  probably  the  least  con- 
fusing, as  these  terms  convey  nothing  but  its  peculiarity,  for  even 
"  Hudson's  tympany "  may  mislead,  since  Dr.  Gee  declares  it  is 
not  "  t_)Tnpanitic  "  at  all. 

It  is  the  clearest  and  most  musical  "  tone  "  or  resonance  yielded 
by  the  thorax,  differing  both  from  pneumothorax  or  emphysema. 
It  is  only  noticed  when  the  effusion  is  very  great  and  during  the 
height  of  its  pressure,  while  its  very  sound  gives  one  the  idea  of 
conditions  of  great  tension  underneath.  In  Dr.  Hayes'  case 
"  loud  bronchial  respiration  with  moist  rales  "  were  heard  over  the 
part,  but,  as  in  my  case,  I  take  the  rales  as  the  first  effort  of  this 
part  of  the  lung  to  regain  its  function  after  compression,  whereas 
the  loud  tubular  breathing  must  be  transmitted  from  elsewhere, 
such  excessive  activity  here  being  incompatible  with  a  perfectly 
placid  side.  Again,  1  found  the  Skodaic  resonance  entirely  dis- 
appear when  the  moist  crepitus  of  returning  function  became 
estabhshed,  almost  proving  its  dependence  on  compression  and 
inactivity  of  the  part. 

Now  in  a  healthy  lung  percussion  produces  a  ^^ clear"  tone  in 
the  bronchi,  but  owing  to  the  defective  conduction  of  the  alternate 
media  of  vesicular  structure  and  air-sacs,  it  reaches  the  surface 
not  as  a  clear,  but  a  "muffled"  resonance.  Could  we  here  inter- 
pose a  more  perfect  conducting  medium  we  should  lose  the  muffling 
and  get  the  bronchial  tones  less  altered. 

For  the  foregoing  reasons  1  believe  the  pathology  of  this  note 
to  be:  Healthy  lung,  compressed  against  the  bronchus  so  tensely  that 
it  is  rendered  function  less,  and  acting  as  a  more  perfect  conductor 
than  the  normal  blood-vascular  vesicular  structure,  transmits  to 
the  front  of  the  chest  the  normal  tracheal  or  bronchial  percussion 
tones  less  muffled  than  in  health,  while  the  rough  bronchial  or 
tubular  breathing  is  also  conducted  from  those  tubes.  As  the 
tension  is  withdrawn  the  tubular  breathing  becomes  less,  the  fine 
moist  crepitation  tells  us  that  the  air  is  re-entering  the  alveoli 
and  inflating  them  once  more,  while  the  peculiar  percussion  sound 
has  entirely  disappeared.* 

*  This  view  is  much  simplified  if  we  believe,  with  Wintrich  and  Dr.  Gee,  "that  the 
minute  vesicular  elements  of  the  lung  and  the  minutest  bronchiols  are  both  singly  and 
collectively  too  small  to  resonate,  the  pulmonary  percussion  tone  being  produced  in 
the  middle-sized  and  largest  bronchia ;  and  the  vesicular  or  spongy  structure  is  nothing 


By  Mr.  W.  Langford  Stmes.  13 

Since  writing  the  above  I  have  had  the  opportunity  of  examin- 
ing this  man's  chest  again  after  a  lapse  of  2  years.  The  left  side 
has  increased  1^  inches  at  the  level  of  the  3rd  rib,  measuring  now 
only  1  inch  less  than  the  right.  At  the  5th  rib  there  is  still  2 
inches  difference  and  1^  at  the  xiphoid  base.  Hy|:>ertrophy  of 
the  right  lung  has  transgressed  the  left  sternal  line  and  raised 
the  right  nipple  to  the  upper  border  of  the  4th  rib  ;  the  left 
nipple  has  fallen  to  the  5th  rib,  but  owing  to  the  depression  of 
the  whole  left  side  and  shoulder  girdle  is  only  ^  inch  further  from 
the  clavicle  than  the  right.  The  apex  beat  is  displaced  upwards 
and  to  the  left  to  half  way  between  the  parasternal  and  left 
mammary  lines  on  the  upper  border  of  the  5th  rib.  This  is  more 
apparent  than  real — the  result  of  the  deformity. 

A  cyrtometric  tracing  at  the  level  of  the  left  nipple  shows  a 
considerable  antero-lateral  diminution  in  the  capacity  of  the  left 
side,  extending  from  the  sternum  to  near  the  angles  of  the  rib, 
and  averaging  a  depth  of  12  mm.  and  a  contraction  posteriorly 
between  the  spine  and  these  angles  of  5  mm.,  while  at  the 
angles  the  left  side  bulges  posteriorly  3  mm.  beyond  the  outline  of 
the  hyper-distended  right  side.  These  discrepancies  being  the 
combined  effects  of  left  contraction  and  right  distension  can  form 
no  criteria  of  the  extent  of  the  former.  Thus  it  is  interesting  to 
note  that  contraction  of  one  side  can  increase  its  measurement  in 
one  diameter  (the  sterno-angular),  that  this  diameter  can  exceed 
that  in  the  hyper-distended  side,  and  that  it  is  produced  by  antero- 
posterior compression  of  the  ribs,  with  protrusion  of  their  angles. 

The  whole  left  side  being  considerably  below  the  level  of  the 

but  an  inert  membrane  as  far  as  concerns  the  production  of  tone."  However,  while 
admitting  the  subordination  of  the  vesicular  structure  to  the  bronchi  in  producing 
tone,  the  dulness  over  pneumonia  prevents  one  accepting  this  in  toto ;  for  then  a 
pneumonic  patch  should  merely  conduct  the  bronchial  percussion  tones  more  clearly, 
as  it  does  the  breathing,  instead  of  sounding  dull. 

Clear  tones  can  be  produced  by  other  conditions,  such  as  over  large  closed  air- 
containing  cavities  with  elastic  walls  of  moderate  tension,  or  a  smaller  air  sac  with  its 
mouth  partly  open  under  greater  tension  ;  but  these  do  not  exist  over  a  pleural  eflfusion. 

Other  explanations  are  : — 

"Relaxation  of  the  pulmonary  tissue"  of  the  German  writers. 

Air  in  the  minute  tubes  of  the  carnified  lung — Dr.  Walsh  ;  while  Dr.  Bristowe 
attributes  it  to  the  diminished  vibrating  area  of  the  thoracic  walls.  Dr.  Goodhart,  in 
an  interesting  paper  on  the  behaviour  of  fluid  in  the  chest  {B.  M.  J.,  June  4,  1887), 
takes  it  as  an  indication  of  generally-impaired  resonance  all  over  the  affected  side, 
produced  by  diminished  volume  of  air  under  the  part  percussed,  or  diminished  vibra- 
tion of  the  walls  of  the  chest.  However,  he  admits  tbat  this  diminished  resonance 
must  have  some  other  cause  besides  the  fluid,  as  this  is  often  very  small. 


14  Pleural  Effusion  with  Displacement  of  the  Heart, 

riifht,  and  no  efforts  liavinix  been  made  to  elevate  it  to  tliis  level 
no  cunature  of  the  spine  has  resulted.  He  enjoys  excellent 
health. 

As  Dr.  Finny's  case  is  a  most  interesting  example  of  left  pleural 
effusion  terminating  in  sudden  death,  his  kind  permission  enables 
me  to  briefly  epitomise  it  here,  as  forming  a  valuable  contrast  to 
mine,  and  since  much  may  be  learned  from  their  analogy : — 

Case. — A  delicate  lad  of  nineteen  was  seen  on  December  21,  1882, 
with  a  pleural  effusion  to  the  6th  rib  and  slight  dextrocardia ;  intercostals 
healthy  ;  decubitus  generally  dorsal  or  towards  the  right  side,  and  in  that 
position  he  used  to  take  his  meals ;  cough,  muco-purulent  sputum ;  I'esp. 
slightly  over  \  of  the  pulse  :  remittent  fever  from  100°  to  103°,  and  pulse 
100  to  120.  The  upper  lobe  of  right  lung  presented  signs  of  numerous 
small  cavities  filled  with  air  and  fluid,  with  comparative  dulness  aud 
coarse  rales,  but  no  bronchophony — conveying  the  idea  that  the  lobe  was 
rapidly  breaking  down.  By  the  27th  the  fluid  had  reached  the  4th  inter- 
space ;  his  breathing  became  much  worse,  with  diffuse  pain  in  left  side  ;  a 
cardio-pleuritic  friction  sound  was  heard  over  the  sternal  ends  of  the 
3rd  interspace  and  4th  rib.  On  the  28th  evening  he  seemed  fairly  well, 
but  his  breathing  was  difiicult ;  he  slept  well,  lying  on  his  right  side,  but 
his  breathing  continued  bad.  The  nurse  roused  him  at  3  a.m.  to  give 
him  nourishment,  raising  him  up  in  bed  to  try  and  ease  his  breathing ; 
his  expression  changed,  indicating  his  end  was  near.  He  became  bathed 
in  perspiration,  and  although  stimulants  were  given,  his  breathing  still 
continued  the  same,  and  he  died  at  5  45  a.m. 

Post-mortem. — The  left  side  was  almost  full  of  fluid  and  the  membranes 
covered  with  recent  lymph.  The  whole  of  the  right  lung  was  adherent  to 
the  ribs,  particularly  the  upper  lobe,  and  the  pleura  was  thickened  all 
over  the  lung :  its  upper  lobe  presented  remarkable  fibroid  changes  hitherto 
undescribed.  The  lobules,  though  mapped  out  and  filled  with  air,  were 
separated  by  fibrous  and  cariilaginous  septa.  The  vesicular  structure  was 
replaced  by  thick  and  dense  fibrous  tissue.  The  whole  lobe  was  honey- 
combed by  a  series  of  minute  labyrinthine  cavities,  varying  in  size  from 
a  pea  to  ^  an  iuch  in  diameter,  while  some  were  quite  discrete  and  un- 
connected with  bronchi. 

In  remarking  on  the  sudden  death  of  this  lad  Dr.  Finny  lays 
great  stress  on  the  rapidity  with  which  the  effusion  is  poured  out, 
and  the  suddenness  of  the  pressure  on  the  heart,  as  conditions  of 
great  danger ;  and  in  attributing  its  fatal  termination  to  a  sudden 
effusion  into  the  pleura  on  the  night  of  his  death,  jegrets  he  was 
not  present  to  draw  off  the  fluid,  although  never  previously  was 
there  any  indication  of  its  necessity. 


By  Dr.  W.  Langford  Symes.  15 

For  many  other  most  interesting  notes  I  must  refer  to  his  ori- 
ginal paper. 

The  comparison  of  these  two  cases  is  most  instructive,  and  their 
analogy  teaches  us  many  facts  which  cannot  be  gathered  from 
either  alone.  Both  cases  of  acute  left  pleurisy,  in  lads  of  the 
same  age,  with  very  peculiar  decubitus.  In  one  the  right  lung 
was  healthy,  and,  as  the  fluid  increased,  yielding  to  the  displaced 
heart,  allowed  it  to  pulsate  freely  on  the  right  side  till  the  effusion 
abated;  w^hile  at  the  same  time,  being  functionally  perfect,  it 
fully  compensated  for  the  loss  of  its  fellow.  In  the  other,  this 
lung  was  diseased,  and  although  the  effusion  was  less,  and  dis- 
placement of  the  heart  slight,  sudden  death  resulted. 

Now,  in  addition  to  imperfect  compensation,  it  seems  probable 
that  the  indurated  lung  and  thickened  pleura  must  have  here 
offered  very  considerable  resistance  to  the  displacement  of  the 
heart,  so  that  the  two  vital  conditions  on  the  part  of  the  opposite 
lung  which  admit  of  such  dislocations  being  produced  with  safety — 
viz.,  freedom  to  yield  and  health  to  compensate — being  seriously 
impaired  by  dense  adhesions  and  chronic  disease,  whatever  chances 
a  simple  case  might  have  Dr.  Finny's  patient  was  deprived  of. 
The  heart,  in  fact,  was  fatally  compressed  against  these  unyielding 
structures. 

The  evidence  in  this  case  of  the  influence  of  high  tension  is 
very  strong  in  that  the  decubitus  was  very  striking,  the  breath- 
ing was  very  difficult,  and  the  right  lung  T-efusing  to  give  way, 
the  heart  was  compressed  into  a  state  of  asystole  against  it." 

I  have  now  under  my  care  a  case  of  left  pleural  effusion  in  a 
feeble  man  of  sixty-seven,  complicated  with  acute  pneumonia  of  the 
right  lower  lobe.  The  heart  is  heard  loudest  under  the  sternum, 
and  the  impulse — if  any — is  here  also.  The  fluid  reaches  the  8th 
rib  behind,  but  not  at  all  in  front.  His  breathing  is  fast,  hut 
since  he  can  lie  and  sleep  in  any  jyosture  on  eithe?'  side,  the  tension 
of  the  fluid  is  low  and  he  is  recovering  without  paracentesis. 

Figure  (5  is  the  bedside  tracing  of  a  young  lad  of  eighteen  on 
the  13th  day  of  his  pleurisy,  with  P.  88,  T.  100",  resp.  32,  fluid 
reaching  the  clavicle  and  crossing  the  sternum  at  the  3rd  rib,  the 

■  Hilton  Fagge,  alluding  to  sudden  death  in  pleurisy,  cites  two  cases,  one  with 
double  pleurisy  and  great  dyspnoea  for  koiue  days  previously,  which  he  attributes  to 
"  exhaustion  of  the  respiratory  centre  ;"  while  in  the  other,  which  died  after  an 
hour's  extreme  dyspnoea,  it  was  observed  that  the  pulse  ceased  before  the  respiration  — 
the  latter  observation  seeming  much  nearer  the  truth. 


16  Pleural  Effusion  with  Displacement  of  the  Heart. 

heart's  impulse  being  between  the  5th  and  6th  ribs  to  tlie  left  of 
the  right  nipple  line,  but  the  maximum  intensity  of  its  first  sound 
under  the  right  side  of  the  base  of  the  xiphoid  cartilage.  Six 
days  later  on  its  return  to  the  left  side  the  centre  of  the  heart  was 
found  betAveen  the  4th  and  5th  right  cartilages,  having  gone  up 
one  space.  In  this  case  there  was  very  little  distress ;  he  lay  and 
slept  on  the  back  inclined  to  the  affected  side,  but  could  turn  well 
on  both.  There  was  no  fainting,  and  "  le  bruit  Skodique  "  was  not 
observed — all  these  points  showing  that  the  tension  of  the  fluid 
must  have  been  low,  although  the  effusion  was  apparently  consider- 
able. We  must  not  forget  that  liquid  may  be  held  in  suspension 
over  the  surface  of  the  lung  to  a  shallow  depth  unaffected  by  the 
laws  of  gravity  ;  and  many  cases  with  a  large  area  of  dulness,  but 
mild  symptoms  and  low  tension,  are  probably  of  this  nature. 

In  concluding  this  subject  for  the  present  the  following  facts 
appear  sufficiently  well-established  to  warrant  their  recapitula- 
tion : — 

1.  That  displacement  of  the  heart  may  occur  as  early  as  the 
fourth  day  ;  that  a  moderate  effusion  can  produce  it ;  and  that  it 
may  be  preceded  and  accompanied  by  fainting  on  exertion. 

2.  That  it  occurs  before  protrusion  of  the  intercostals,  and 
the  heart  may  even  pulsate  beyond  the  right  nipple  while  they 
are  not  affected. 

3.  That,  owing  to  the  peculiar  basic  attachments  of  the  heart, 
the  apex  can  move  in  the  arc  of  a  circle,  right  or  left ;  that  the 
heart  appears  to  rotate  upon  its  long  axis  ;  and  that  this  rotation 
in  dexiocardia  may  increase  the  distinctness  of  its  sounds  and 
impulse. 

4.  That  the  heart  does  not  return  by  the  same  route,  but  on  a 
plane  somewhat  higher,  and  that  this  course,  whether  real  or 
apparent,  is  dependent  upon  the  non-expansion  of  the  lung. 

5.  That  extreme  displacement  may  exist  without  either  hruit  or 
palpitation,  and  does  not  ipso  facto  necessitate  paracentesis. 

6.  That  it  is  extremely  dangerous  for  the  patient  to  undergo 
any  exertion  when  it  is  so  displaced,  owing  to  the  many  risks  of 
sudden  death. 

7.  That  decubitus  on  the  sound  side,  or  in  a  semi-dorsal  position 
inclined  to  that  side,  appears  to  lessen  the  tension  of  the  fluid ; 
that  it  is  always  a  grave  symptom,  and  an  urgent  indication  for 
paiacentesis  to  relieve  tension. 

8.  That  "  le  bruit  Skodique "  is  caused  by  the  compression  of 


Trephining  for  Meningitis.  17 

healthy  lung  against  the  bronchus,  thus  acting  as  a  better  con- 
ductor of  sound ;  that  it  is  closely  connected  with  high  tension ; 
and  that  it  disappears  when  the  intra-thoracic  pressure  falls. 

9.  That  the  dangers  of  displacement  being  intimately  connected 
with  the  condition  of  the  opposite  lung,  the  extent  of  dislocation, 
per  se,  forms  no  criterion — some  slight  displacements  ending 
fatally,  while  other  extreme  ones  are  borne  with  impunity. 


Art.  U.— Trephining  for  Meningitis.^  By  J.  S.  M'ArdLE, 
F.R.C.S. ;  Surgeon  and  Lecturer  on  Clinical  and  Operative 
Surgery,  St.  Vincent's  Hospital. 

In  bringing  this  subject  under  your  notice,  I  have  two  objects 
in  view.  1st,  to  place  on  record  a  case  which  I  will  hereafter 
detail ;  and  2nd,  to  eHcit  your  opinion  in  reference  to  a  line  of 
treatment  which  suggests  itself  to  me  for  the  relief  of  some,  at 
least,  of  the  forms  of  meningeal  inflammation.  We  have  all  seen 
cases  of  syphilitic  tubercular  and  traumatic  meningitis  die,  and 
not  infrequently  does  a  meningeal  effusion  terminate  life  in  cases 
of  alcohohsm.  Now,  elsewhere,  in  areas  open  to  sm-gical  inter- 
ference, in  cases  where  tension  is  tending  to  a  fatal  result,  local 
or  general,  we  aim  at  relief  of  that  tension  by  incision  and  free 
drainage,  and  I  think  the  time  has  amved  for  applying  this 
surgical  principle  to  the  last  of  the  closed  cavities,  to  be  handed 
over  to  the  tender  mercies  of  the  surgical  side  of  the  profession. 
For  long  the  physicians  could  not  see  their  way  to  surgical 
intervention  in  cases  of  serous  or  other  collection,  in  the  peri- 
toneum, plem'a,  or  pericardium ;  but  the  advances  of  modern 
surgery  have  emboldened  them,  and  far  from  in  any  way  im- 
peding om-  advance,  they  are  the  first  to  see  the  necessity  for  all 
justifiable  operations  on  these  regions. 

We  still  linger  by  the  cradle  of  brain  surgery,  and  let  us  hope 
that  with  the  aid  of  the  highly  skilled  diagnosticians  whom  we 
now  boast,  we  may  om-selves  witness  the  advantages  of  its 
adolescence. 

The  case  I  am  about  to  detail  is  an  instance  in  which  I  felt 
that  vigorous  surgical  interference  was  demanded  but  woidd 
not  be  permitted,  and  you  will  agree  with  me  that  life  might 
have  been  saved  if  my  suggestion  had  been  carried  out. 

*  Eead  before  the  Section  of  Surgery  of  the  Royal  Academy  of  Medicine  in  Ireland, 
on  Friday,  May  20,  1892.     [For  the  discussion  on  this  paper  see  page  78.] 

C 


]  8  Trephining  for  Meningitis. 

Case  I. — James  Egan,  aged  thirty-eight  years,  was  crushed 
by  a  horse  against  the  side  of  his  stall,  sustaining  injm-ies  to  his 
chest  and  back.  After  a  time  he  complained  of  severe  pain  in 
the  back  and  right  side  of  head,  gradual  loss  of  strength,  and 
general  mental  weakness.  He  came  under  my  care  in  the  follow- 
ing condition  on  May  10th,  1890: — 

He  was  apathetic,  answered  questions  veiy  slowly,  and  all 
response  to  questions  of  any  kind  was  very  tardy.  His  pulse 
was  slow  (50  per  minute),  soft,  and  full.  Temperatm-e  sub- 
normal, ranging  from  95*6''  to  97'8°,  occasionally  in  the  evening 
reaching  98°.  From  the  first,  emotions,  if  he  experienced  any, 
affected  only  his  inner  self,  his  blank  face  never  bearing  any 
evidence  of  their  existence.  He  was  able  to  move  about,  but 
his  movements  seemed  pm-poseless.  All  through  he  took  nourish- 
ment freely,  and  the  m-inary  and  digestive  systems  were  normal. 

All  om-  efforts  at  relieving  the  distress  by  bhstering  and  the 
exhibition  of  mercury  proved  fruitless,  the  patient  going  from  bad 
to  worse,  first  losing  control  of  his  legs  (a  condition  necessitating 
confinement  to  bed),  then  a  similar  condition  of  the  arms  set  in, 
so  that  he  was  never  able  to  assume  a  desired  position  without 
aid. 

The  power  of  co-ordination  was  completely  lost,  while  muscular 
action  was  not  interfered  with.  If  asked  to  put  his  hand  to  his 
head  or  to  reach  for  anything,  the  result  was  painful  to  witness. 
The  poor  fellow  would  vainly  endeavour  to  control  the  move- 
ments of  the  limb,  which  generally  went  in  every  direction  but 
the  proper  one  ;  and  usually  when  the  other  arm  was  requisitioned 
to  aid  the  unsteady  member,  a  series  of  eccentric  bimanual 
movements  resulted — rarely,  indeed,  ending  in  the  performance 
of  the  desired  act.  This  state  of  things  continued  for  some  days, 
then  deglutition  and  respiration  became  affected ;  and,  notwith- 
standing all  our  efforts,  he  died  on  May  26th,  1890. 

The  post  mortem  revealed  a  thickening  of  the  membranes  of  the 
upper  part  of  the  cord ;  and  at  the  base  of  the  brain,  effusion 
under  the  tentorimn,  compressing  the  cerebelhnn  and  medulla, 
was  found  to  be  the  cause  of  death. 

Now  this  is  a  case  in  which  there  was  no  direct  cranial  injury, 
but  nevertheless  death  resulted  from  intra-cranial  pressiu-e,  and 
a  trephine  opening  into  the  cerebellar  fossa  would  have 
relieved  the  symptoms  and  probably  saved  life  ;  and  my  sugges- 
tion is,  that  what  we  do  for  intra-osteal  pressure  elsewhere  should 


By  Mr.  J.  S.  M'Ardle.  19 

be  done  in  such  cases  whether  arising  as  the  result  of  tubercular, 
syphilitic,  or  other  meningeal  inflammation.  I  have  examined 
the  membranes  of  the  brain  in  fatal  cases  of  tubercular  mening- 
itis, and  although  the  majority  showed  diffuse  meningeal 
thickening,  I  can  recall  several  in  which  only  a  few  small,  grey 
nodules  were  found,  such  as  are  discovered  in  cases  of  peritoneal 
tuberculosis  which  end  favourably  after  irrigation.  A  similar 
result  should,  at  least  in  some  cases,  follow  interference  in  the 
cases  under  discussion.  The  case  I  have  just  related  occurred 
in  a  syphilitic  subject,  and,  no  doubt,  his  constitutional  condi- 
tion at  the  time  of  the  accident  predisposed  him  to  the  affection 
from  which  he  ultimately  died;  but  the  post  mortem  disclosed 
only  a  removable  cause,  and  one  which,  but  that  my  hands 
were  tied,  would  have  been  removed,  and  very  probably  with 
success. 

The  next  case  which  I  am  about  to  relate  comes  within  the 
category  of  inflammatory  troubles,  although  some  would  say 
that  it  was  one  of  subdural  haemorrhage. 

Case  II. — Wilham  Green,  aged  forty,  was  admitted  to  Saint 
Vincent's  Hospital  on  the  3rd  December,  1890,  when  the  follow- 
ing history  was  ehcited : — On  Saturday,  November  15th,  he  fell 
into  the  hold  of  a  vessel,  striking  the  left  side  of  his  head ;  he 
was  removed  in  an  unconscious  condition  to  Su-  Patrick  Dun's 
Hospital,  where  a  wound  over  the  left  eye  was  dressed.  In  a 
few  hours  consciousness  returned,  and  he  went  home  the  same 
evening.  The  next  day  being  Sunday,  he  rested,  and  on  Mon- 
day resumed  his  work  as  coalporter.  All  went  well  with  him 
until  Monday,  December  1st,  when  he  felt  disinchned  for  work, 
had  some  sickness  of  stomach,  and  noticed  his  left  hand  weak. 
Dm-ing  the  evening  of  that  day  he  experienced  severe  pain  in 
the  top  of  his  head,  and  the  weakness  of  the  arm  increased.  On 
Tuesday,  sixteen  days  after  the  accident,  he  found  the  left  leg 
becoming  powerless,  and  the  foUownng  day  he  came  under  my 
care.  He  then  had  partial  paralysis  of  left  arm  and  leg.  There 
was  a  scar  over  the  left  eye ;  pulse,  54 ;  temperatm-e,  96-5° ; 
pupils  normal,  and  respond  to  hght.  Although  he  seemed  stupid 
he  answered  quickly  and  accurately.  I  had  his  head  shaved, 
and  the  most  careful  examination  did  not  disclose  any  external 
evidence  of  injury  on  the  right  side.  It  was  evident  from  the 
slow  pulse  and  sub-normal  temperature,  as  well  as  the  paralysis, 
that  compression  of  the  brain  was  present. 


20  Trephining  for  Meningitis. 

The  histoiy  (early  unconsciousness,  then  an  interval,  and  now 
rather  rapid  occurrence  of  paralysis)  pointed  to  secondary 
hajmorrhage  ;  but  the  fact  that  pressiu-e  symptoms  so  gradually 
increased  convinced  me  that,  although  a  haemorrhage  might  be 
the  primaiy  cause,  inflammatory  trouble  must  have  supervened. 
Ice  was  applied  to  head,  and  mercury  administered;  but  the 
symptoms  gi-ew  worse,  until,  on  the  morning  of  the  5th  (fifty 
hom-s  after  admission),  the  following  note  was  sent  to  me  by 
Dr.  Garret  Hickey,  to  whose  able  assistance  are  due  many  of  my 
successes,  both  in  private  and  in  hospital  practice  : — 

"  Dec.  5th — Green  slept  pretty  well  during  the  night ;  but 
at  6  a.m.  I  was  called,  to  find  that  he  had  just  had  a  convulsive 
attack,  which  weakened  hun  very  much.  At  7  20,  I  saw  him 
again,  and  learned  that  in  the  interval  he  had  had  several,  only 
5  to  10  minutes  elapsing  between  each."  The  attack  which 
caused  him  to  send  an  m-gent  message  for  me  he  describes  as 
follows : — "  The  fingers  of  the  left  hand  contract  fii-mly  into 
palm.  The  hand  is  then  flexed  on  the  forearm  ;  pronation  then 
takes  place  while  the  arm  is  being  elevated  straight  up  from 
the  body.  About  this  time  deviation  of  the  eyes  to  the  right 
occm*s,  and  the  face  soon  follows  in  the  same  direction,  contrac- 
tion of  left  face  being  marked  (for  the  first  time  gm-gling  in 
the  throat  and  difficulty  of  breathing  are  noticed) ;  the  arm  now 
di-ops,  not  suddenly,  but  by  short  jerks,  and  the  left  leg  works 
convulsively."  He  winds  up  this  hm-ried,  but  accm-ate  and 
expressive  note  by  saying,  "  I  would  wish  you  to  come  as  soon 
as  possible.  He  is  perspiring  freely,  and  is  much  exhausted 
after  the  exertion."  I  hurried  to  the  hospital,  saw  a  repetition 
of  the  performance,  so  well  described  by  Mr.  Hickey,  and  a 
picture  of  greater  distress  I  never  witnessed.  Fortunately,  the 
patient  was  totally  unconscious,  and  had  been  so  for  some  time. 
The  temperature  was  still  subnormal,  and  the  pulse  varied  from 
45  to  50  per  minute.  In  the  last  attack  which  1  witnessed,  and 
the  last  we  allowed  him  to  get,  respiratory  difficulty  was  very 
pronounced,  the  poor  fellow  becoming  cyanosed.  I  felt  that 
further  delay  would  be  criminal.  Removing  him  to  the  theatre, 
I  at  once  removed  the  piece  of  bone  exhibited  (Fig.  1.)  The 
dm-a  mater  projected  into  the  wound,  looking  very  dark.  On 
incising  it,  a  greenish,  serous  fluid  gushed  out,  and  on  raising 
the  membrane,  after  detaching  it  three-fom-ths  of  the  way 
round,  I  found  a  clot  adhering  firmly  to  its  inner  surface.     This 


By  Mr.  J.  S.  M'Ardle.  21 

I  scraped  away.  After  thoroughly  irrigating  the  parts  witli 
boracic  sohition,  I  sutured  the  dm-a  mater,  laid  a  medium  sized 
drainage-tube  across  the  wound,  passing  deep  sutures  to  fix  the 
scalp  flap.  For  some  time  there  was  a  copious  serous  oozing, 
which  necessitated  frequent  change  of  the  dressings ;  but  late 
in  the  evening  drainage  seemed  complete,  and  at  3  a.m.  on  the 
6th,  consciousness  retm-ned,  the  patient  raising  at  the  same 
time  the  arm  which  had  been  paralysed,  and  saying  to  the  nurse 
in  charge,  "  Begor,  iVe  the  use  of  myself,  ma'am." 


Fig.  1. 

From  this  time  recovery  was  uninterrupted,  and  on  the  14tb, 
that  is,  eight  days  after  operation,  the  patient  was  about,  the 
wound  being  soundly  healed.  The  ultimate  result  of  the  opera- 
tion you  have  witnessed.  The  patient  you  have  examined  has 
never  lost  one  day's  work  through  ill  health  since  his  dismissal 
from  our  convalescent  home,  one  month  after  operation. 

In  determining  the  position  at  which  to  apply  the  trephine,  I 
was  guided  chiefly  by  the  starting  point  of  the  spasms,  and  I 
cut  down  in  the  area  which  gave  me  the  greatest  chance  of 
reaching  the  hand  and  arm  centres,  as  the  convulsive  seizm-es 
started  in  these  centres,  and  spread  to  those  of  the  face  down- 
wards, and  to  those  of  the  leg  upwards. 

Fig.  2  shows  the  exact  situation  in  which  I  trephined,  as  you 
may  see  by  comparing  the  plate  with  the  patient's  head.  Now 
this  was  the  exact  spot  at  which  an  adherent  clot  was  found, 
and  when  we  come  to  study  the  next  plate.  Fig.  3,  we  find  that 
this  area  corresponds  exactly  with  the  supposed  situation  of  the 
hand  and  arm  centres,  and  one  can  easily  explain  the  course  of 
the  case  from  gradual  loss  of  power  of  the  hand  and  arm  to  a 
loss  of  power  of  the  lower  extremity,  and  ultimately  to  a  com- 
plete left-sided  paralysis.  Extension  forwards  of  the  pressm*e 
would  explain  the  conjugate  deviation  of  the  eyes  towards  the 


22 


Treplining  for  Meningitis. 


side  of  the  lesion,  and  extension  backwards  would  account  for 
loss  of  sensation  and  of  consciousness. 


Fig.  2. 

In  this  case  a  small  blood  clot  was.  no  doubt,  the  starting-point 
of  the  trouble,  but  a  localised  meningitis  was  the  coucUtion  for 
which,  after  consultation  with  my  colleagues,  I  trephined  this 
man.  The  operation  confirmed  the  diagnosis,  and  the  result 
which  you  have  witnessed  fully  justified  the  undertaking.  Before 
operation  I  was  careful  to  mark  the  Hne  of  Rolando's  fissure, 
but  when  the  patient  was  anaesthetised  and  brought  into  the 
theatre,  I  did  not  like  the  direction  of  the  line  marking  the 
fissure,  and  on  re-measuring  the  fronto-occipital  line  I  found  that 
on  the  previous  occasion  I  had  placed  the  upper  end  of  that 
line  half  an  inch  too  far  forward,  as  in  the  first  marking  I  had 
comjnenced  the  measurement  by  placing  on  the  tape  (vide  Fig.  4) 
at  the  root  of  the  nose,  and  thus  in  subdividing  the  distance  a 


By  Mr.  J.  S.  M'Ardle. 


23 


Fig.  3. 


:      31  4 


Fig.  4. 

diiference  of  half  an  inch  occurred.  Now,  as  the  clot  removed 
was  adherent  to  the  dura,  a  faulty  marking  might  have  led  to 
less  favourable  ending.  I  merely  mention  this  error,  as  it  is 
possible  others  could  fall  into  a  similar  one,  and  the  warning- 
may  be  of  service.  Dming  the  operation,  Mr.  Patteson,  who 
had  charge  of  the  patient,  called  my  attention  to  a  cm-ious  effect 
of  the  working  of  the  trephine,  the  explanation  of  which  I  would 
be  glad  to  elicit.  Before  operation  and  during  the  intervals 
occupied  in  examining  the  depth  of  the  trephine  wound,  the 


24 


Trephining  for  Meningitis. 


pulse  never  was  above  54  per  miniite.  The  moment  I  exerted 
pressure  the  pulse  went  up  to  80,  and  this  change  occm-red  on 
every  similar  occasion  all  through  the  operation. 

Before  definite  symptoms  of  meningitis  showed  in  this  case 
my  notion  was  that  secondary  efiusion  of  blood  occm-red  during 
some  effort  at  lifting  heavy  weights,  and  I  was  dehberating 
over  which  of  the  haemorrhagic  areas  described  by  Kronlein, 
and  depicted  in  the  accompanying  woodcut,  Fig.  5,  it  would 
be  advisable  to  trephine  should  no  improvement  take  place. 


Fig.  5. 


That  in  perforating  the  skull  in  the  situations  selected  one 
strikes  important  meningeal  branches  is  shown  by  the  pieces 
here   depicted — Fig.   6 — which   I   removed   by    a   trephine   of 


Fig.  6. 


By  Mr.  J.  S.  M'Ardle.  25 

only  8  mms. — one  comes  on  the  anterior,  the  other  on  the  pos- 
terior division  of  the  middle  meningeal  artery.  In  the  absence 
of  definite  focal  symptoms,  and  with  symptoms  of  meningeal 
hsemon-hage,  I  would  be  inclined  to  adopt  Kronlein's  suggestion 
and  seek  the  clot  in  either  of  the  positions  marked  out,  as  a 
trephine  of  16  or  20  mm.  would  expose  with  certainty  clots  or 
effusions  of  any  size  if  applied  at  the  points  indicated. 

As  the  diagi'am  is  instructive  I  take  the  liberty  of  laying  it 
before  the  Academy,  in  the  hope  that  some  members  more  versed 
in  the  anatomy  of  the  cranium  than  I  am  may  express  an  opinion 
on  its  merits  or  demerits  as  a  guide  in  operations  on  that  part. 

The  points  of  the  case  I  desu-e  to  recall  are — 1st,  there  was 
unconsciousness  immediately  after  the  accident  lasting  somq 
hours;  2nd,  there  was  no  trace  of  injmy  to  the  right  side  of 
the  scalp ;  3rd,  there  was  evidence  of  a  wound  over  the  left 
eye  ;  4th,  the  patient  worked  at  a  laborious  occupation  for  well- 
nigh  thi-ee  weeks  after  the  injury ;  5th,  death  was  imminent 
from  laryngeal  spasm  immediately  before  operation ;  6th,  serum, 
not  blood,  was  the  immediate  cause  of  pressure  symptoms ;  and 
7th,  the  membranes  were  thickened  and  showed  that  meningitis 
had  been  set  up. 

Some  years  ago,  when  the  question  of  siu-gical  treatment  of 
intra-cranial  haemorrhage  was  so  ably  stated  here,  the  term  "  ti-e- 
phining-epidemic  "  and  such  epithets  were  used,  reminding  one 
of  similar  expressions  regarding  operations  on  the  abdomen 
when  the  surgery  of  that  cavity  was  forging  ahead  in  spite  of 
every  obstacle.  To  no  chapter  in  the  history  of  om-  art  can  the 
student  of  sm-gery  tm-n  with  gi-eater  pleasm-e  than  to  that  on 
the  modern  sm-gery  of  the  brain,  and  none  can  he  peruse  with 
greater  profit ;  and  I  may  be  forgiven  if  I  say  that  I  am  proiid 
that  the  impress  of  Irish  surgery  is  there  indehbly  stamped,  and 
that  by  members  of  this  Section  of  the  Academy.  Feeling  that 
I  only  add  a  brief  and  halting  record  to  this  glorious  page,  I 
can  but  crave  yoiu-  pardon  for  thus  occupying  yom'  time  and  to 
such  sHght  purpose. 


2G      Suspected  Per/oration  of  Chronic  Ulcer  of  the  Stomach. 

Art.  III. —  The  Desirability  of  Operative  Interference  in  Suspected 
Perforation  of  Chronic  Ulcer  of  the  Stomachs  By  Alfred  R. 
Parsons,  M.B.  (Univ.  Dubl.) ;  late  House  Surgeon  in  Sir  P. 
Dun's  Hospital. 

Pathological  observation  and  experimental  investigation,  parti- 
cularly the  latter,  have  done  much  to  aid  clinical  diagnosis,  and 
to  render  feasible  operations  which  seemed  little  short  of  impious 
to  our  forefathers.  The  physician  can  often,  from  the  clinical 
history  and  symptoms,  now  localise  a  cerebral  abscess  with  suffi- 
cient certainty  to  justify  a  surgeon  in  applying  his  trephine  and 
attempting  to  drain  it.  A  clearer  knowledge  of  the  origin  and 
functions  of  the  spinal  nerves  has  enabled  the  neurologist  to  point 
accurately  to  a  certain  level  as  the  seat  of  spinal  pressure,  and 
the  surgeon's  knife  has  confirmed  the  accuracy  of  the  diagnosis, 
and  by  the  removal  of  the  tumour  made  life  a  pleasure  where  it 
had  been  full  of  pain.  Certain  s^Tiiptoms  and  signs  referable  to 
one  hyj3ochondriac  region,  and  the  presence  in  the  urine  of  a 
small  quantity  of  caseous  pus,  containing  tubercle  bacilli,  justify, 
with  certain  restrictions,  a  recommendation  of  surgical  interfer- 
ence, and  the  excision  of  a  kidney  with  a  localised  tubercular  focus 
has  saved  an  otherwise  forfeited  life.  Opening  the  peritoneal 
cavity  demanded  at  one  time  no  less  an  atonement  than  the  life 
of  its  possessor ;  but  to-day  the  surgeon,  strong  in  his  antiseptic 
precautions,  does  an  exploratory  laparotomy  with  greater  coolness 
and  confidence  than  he  can  find  in  the  administration  of  chloro- 
form to  a  child.  But  though  much  has  been  done  in  the  past, 
and  many  lives  have  been  saved  by  the  combined  action  of  physi- 
cian and  surgeon,  much  still  remains  to  be  done,  and  I  trust  that 
the  day  is  not  far  distant  when  the  man  who  dallies  with  acute 
perforative  peritonitis  will  be  equally  guilty  with  the  practitioner 
who  follows  the  hounds  knowing  a  patient  of  his  is  suffering  from 
a  strangulated  hernia,  and  then  calls  in  some  one  else  to  share 
the  responsibility  with  him.  To  one  of  the  causes  of  acute  per- 
forative peritonitis — namely,  chronic  ulcer  of  the  stomach — I 
desire  in  this  paper  to  refer ;  and  I  would  wish,  from  my 
very  limited  experience,  to  attempt  to  deduce  the  phenomena 
which  indicate  the  occurrence  of  perforation,  and  then  suggest 
what  seems  to  be  the  only  line  of  treatment  offering  any  hope  of 

'  Read  before  the  Section   of  Medicine  in  the  Royal   Academy  of  Medicine  in 
Iru-laud,  on  Friday,  May  6,  1892.     [For  the  discussion  on  this  paper  see  page  76.J 


By  Dr.  Alfred  R.  Parsons.  27 

success.  The  following  cases  came  under  my  notice  last  year,  as 
House  Surgeon  in  Sir  P.  Dun's  Hospital,  and  my  best  thanks  are 
due  to  the  staff  of  the  hospital  for  permission  to  record  them,  and 
for  the  assistance  they  gave  me  in  looking  up  the  literature  bear- 
ing on  this  subject : — 

Case  I. — Michael  C,  aged  twenty-seven,  a  well-built,  muscular  man, 
was  brought  to  hospital  about  9  a.m.  on  Saturday,  2Sth  March,  in  an 
almost  unconscious  condition.  The  history  we  obtained  from  his  friends 
was,  that  he  had  been  engaged  at  his  usual  work,  and  apparently  in 
perfect  health,  till  12  noon  on  the  previous  day,  when  he  was  seized 
with  violent  abdominal  pain,  which  doubled  him  in  two.  He  went  to 
bed,  and  as  the  pain  did  not  subside,  medical  aid  was  called  in.  The 
doctor  who  saw  him  administered  castor-oil  and  opium  by  the  moutli, 
applied  stupes  to  the  abdomen,  and  gave  an  enema.  His  relatives  weie 
advised  to  have  him  moved  to  hospital  the  following  morning,  if  there 
were  not  a  decided  improvement  in  his  condition.  During  the  afternoon 
he  vomited  some  reddish-coloured  fluid,  which  was  thought  to  be  blood. 
He  passed  rather  a  sleepless  night,  suffering  considerable  pain,  but  was 
able  the  following  morning  to  assist  in  dressing  himself,  preparatory  to 
removal  to  hospital.  On  admission  he  was  cyanosed,  pupils  were  dilated, 
sweating  on  forehead,  pulse  almost  imperceptible,  abdomen  somewhat  dis- 
tended and  very  tympanitic.  Complete  loss  of  liver  dulness.  It  soon  became 
impossible  to  feel  the  pulse  at  the  wrist,  and  within  fifteen  minutes  after 
admission  respiration  had  ceased.  In  this  case  the  physical  signs,  com- 
bined with  the  history,  left  little  doubt  that  we  were  dealing  with  a 
perforation,  and  the  diagnosis  of  acute  peritonitis  due  to  perforating 
ulcer  of  the  stomach  was  almost  quite  accurate.  At  the  post-mortem 
examination  we  found  recent  acute  generalised  peritonitis,  evidently 
produced  by  the  rupture  of  a  small  round  ulcer  situated  just  at  the 
commencement  of  the  duodenum.  The  other  organs,  as  far  as  they 
were  examined,  appeared  quite  free  from  disease. 

Case  II. — Miss  M.  G.,  aged  twenty-one,  was  admitted  to  Sir  P.  Dun's 
Hospital  about  10  30  p.m.  on  Saturday,  the  28th  November,  1891, 
suffering  from  intense  abdominal  pain.  She  told  us  tliat  her  general 
health,  with  the  exception  of  occasional  attacks  of  constipation,  accom- 
panied by  pain,  had  been  good  till  the  onset  of  her  present  illness.  She 
gave  no  account  of  vomiting  blood  or  of  pain  after  taking  food.  The 
history  of  her  illness  dated  from  Thursday,  25th  November,  though  since 
the  previous  Sunday  there  had  been  no  motion  of  the  bowels,  and  she 
had  had  slight  attacks  of  pain  referred  to  the  abdomen.  These  attacks, 
however,  were  not  sufiiciently  severe  to  have  prevented  her  from  attending 


2.^      Siispfcted  Perforation  of  Chronic  Ulctr  of  the  Stomach. 

to  her  daily  work.  On  Thursday,  at  8  p.m.,  just  two  days  before  her 
admission  to  hospital,  she  was  seized  suddenly  with  an  attack  of  violent 
abdominal  pain,  accompanied  by  vomiting.  On  the  next  day,  as  the 
pain  was  still  very  severe  and  the  vomiting  continued,  the  family  phy- 
sician was  called  in.  He  administered  soap  and  water  enemata,  and 
glycerine  enemata,  but  failed  to  move  the  bowels.  A  dose  of  castor-oil, 
which  was  not  vomited,  was  likewise  ineffective.  On  the  following  day 
(Saturday)  Dr.  Ball  was  asked  to  see  the  patient  in  consultation.  He 
visited  her  in  the  afternoon  and  recommended  her  immediate  removal  to 
hospital.  On  admission  some  four  hours  later  the  patient,  who  was  well 
nourished  and  developed,  appeared  to  be  suffering  considerable  pain. 
The  cheeks  were  of  a  bluish  red  hue,  but  the  lips,  conjunctivae,  and 
gums  were  rather  anaemic.  The  tongue  was  coated  with  white  fur,  and 
tlie  breath  was  foetid.  Respirations  were  hurried  (45  per  minute),  and 
the  alfe  nasi  were  working  actively.  The  frequency  of  the  pulse  was 
likewise  considerably  increased — 132  per  minute,  small  in  volume  and 
feeble.  Her  heart  and  lungs  showed  no  indication  of  organic  disease. 
The  temperature  was  96°  F.  The  abdomen  was  considerably  distended, 
though  not  uniformly  tympanitic ;  it  was  tender  to  the  touch,  but  the 
pain  was,  of  anything,  referred  rather  to  the  left  than  to  the  right  side. 
The  area  of  hepatic  dulness  was  reduced  to  about  two  fingers'  breadth. 
After  consultation  it  was  decided  to  postpone  operative  measures  till  the 
following  morning,  in  the  hope  that  the  patient  would  then  have  recovered 
from  the  shock  consequent  on  moving  her,  and  that  the  advantage  of 
operating  in  daylight  would  more  than  counterbalance  any  risk  attendant 
on  a  delay  of  9  or  10  hours.  She  had  some  morphin  during  the  night,  and 
the  following  morning,  though  her  condition  was  very  critical,  it  seemed 
that  an  operation  would  afford  her  the  only  chance  of  recovery.  It  was 
thought  probable,  from  the  history  of  the  case,  and  particularly  from  the 
fact  that  the  perforation — if  perforation  it  were — must  have  occurred  some 
56  or  6U  hours  previously,  that  the  lesion  was  connected  with  the  vermi- 
form appendix.  The  abdomen  was  therefore  opened  in  the  middle  line, 
between  the  umbilicus  and  symphysis  pubis.  All  the  indications  of  lecent 
acute  peritonitis  were  present,  but  a  careful  examination  of  the  vermiform 
appendix  and  pelvic  viscera  failed  to  disclose  the  cause.  Dr.  Ball  then 
proceeded  to  explore  the  upper  part  of  the  abdomen,  but  finding  the 
transverse  colon  perfectly  free  from  any  inflammation,  concluded  that 
the  source  of  the  mischief  could  not  lie  in  that  direction.  The  cavity 
was  accordingly  flushed  out  with  warm  water,  and  a  drainage  tube  was 
inserted.  The  patient  died  that  evening  at  6  o'clock.  A  post-mortem 
examination  disclosed  the  presence  of  a  perforating  ulcer,  situated  about 
the  middle  of  the  anterior  wall  of  the  stomach.  One  of  the  most  unusual 
features  in  this  case  is  the  length  she  survived  the  perforation.  Hilton 
Fagge  says  that  if  the  patient  live  more  than  one  day  after  the  onset  of 


By  Dr.  Alfred  R.  Parsons.  29 

perforative  peritonitis,  the  probabilities  point  strongly  to  a  perforation  of 
the  vermiform  appendix,  as  nearly  all  the  cases  of  ruptured  ulcer  of  the 
stomach  are  fatal  in  less  than  24  hours. 

Case  III. — About  9  15  a.m.  on  Monday,  21st  December,  1891,  I  was 
asked  to  see  a  lady  who  had  been  a  patient  in  the  hospital  on  three  or 
four  occasions  during  the  years  1890  and  1891,  suffering  from  attacks  of 
severe  pain  referred  to  the  stomach.  These  attacks  were  not  very  closely 
related  to  meal  times,  as  they  occurred  sometimes  before,  sometimes 
after,  and  often  quite  independently  of  partaking  of  food.  She  never 
vomited  any  blood.  Consequently,  though  gastric  ulcer,  amongst  other 
possible  diagnoses,  presented  itself  to  the  minds  of  those  under  whose 
care  she  was,  I  am  not  aware  that  any  absolute  diagnosis  had  been  made 
in  her  case.  These  attacks  of  pain  had  often  been  greatly  relieved  by 
taking  10  grs.  of  antipyrin.  I  heard  she  had  returned  from  her  pro- 
fessional duties  only  the  previous  evening,  and  learned  from  herself  that, 
four  days  previously,  an  attack  of  pain  more  severe  than  usual  had  set 
in.  Though  she  continued  at  her  work  she  was,  owing  to  the  severity  of 
the  pain,  able  to  take  but  little  food  during  this  period.  She  returned  to 
town  on  Sunday  evening,  but  could  not  sleep  till  6  o'clock  the  following 
morning.  She  slept  then  for  some  two  hours,  and  awoke  a  little  after  8 
in  most  violent  pain.  I  was  accordingly  asked  to  see  her,  and  found 
her  about  9  30  a.m.  still  suffering  considerably.  She  referred  the  pain 
chiefly  to  the  left  hypochondriac  region.  The  pulse  was  100  per  minute, 
respirations  were  tolerably  deep.  An  examination  of  the  region  to  which 
the  pain  was  referred  failed  to  detect  anything  abnormal.  On  ausculta- 
tion the  heart  sounds  seemed  unaccountably  feeble.     I  regret  to  say  that 

I  failed  to  recognise  the  nature  of  this  case  at  once,  because  I  did  not 
grasp  the  fact  that  she  had  had  a  sudden  onset  of  very  violent  pain  at 
8  a.m.,  and  I  understood  from  her  that  the  pain  was  not  quite  so  bad  as 
it  had  been  a  little  previously.  I  recommended  the  application  of  stupes 
to  the  side,  and  administered  a  small  quantity  of  a  stimulating  carmina- 
tive mixture.  However,  on  thinking  over  the  ease  it  struck  me  that 
very  probably  it  was  a  perforation  that  had  taken  place,  and  I  was 
confirmed  in  this  opinion  when  I  saw  her  an  hour  or  so  later ;  for  at 

II  a.m.  the  collapse  was  much  more  marked,  the  frequency  of  the  pulse 
had  increased  to  110,  finger  nails  were  blue,  face  was  drawn  and  anxious, 
and  notwithstanding  application  of  stupes  and  hot  bottles  patient  was 
rather  cold.  Dr.  Finny  saw  her  shortly  afterwards,  and  it  was  decided  to 
remove  her  to  hospital.  A  hypodermic  of  morphin  and  a  stimulating  enema 
were  administered  by  his  directions,  and  soon  after  her  admission  she  rallied 
considerably,  but  the  frequency  of  her  pulse  had  increased  to  120.  On 
examination  the  area  of  hepatic  dulness  was  found  to  be  diminished,  and 
the  note  over  the  hepatic  region  abnormally  tympanitic.     A  catheter  was 


30      Suspcrf.d  Perforation  of  Chronic  Ulcer  of  the  Stomach. 

passed  and  several  ounces  of  urine  free  from  albumen  and  indican  we'-e 
drawn  off.  A  soap  and  water  enema  removed  a  small  quantity  of  fiBc^il 
matter.  By  Dr.  Finny's  order  a  consultation  of  the  staff  to  decide  on 
the  advisableness  of  operative  measures  was  summoned  for  4.  By  this 
time  the  pulse  had  increased  somewhat  more  in  frequency,  but  otherwise 
there  was  no  marked  change  in  her  condition.  After  consultation  it  w;is 
decided  to  open  the  abdomen.  Dr.  Ball  made  the  incision  in  the  middle 
line  above  the  umbilicus,  and  the  moment  the  peritoneum  was  incised 
an  escape  of  gas  confirmed  the  diagnosis  of  a  perforation,  the  sit«  of 
which  was  found  to  be  the  anterior  wall  of  the  stomach,  in  its  lesser 
curvature  near  its  junction  with  the  oesophagus. 

The  wall  of  the  stomach  all  round  the  perforation  was  thickened, 
swollen,  and  so  soft  that  sutures  at  once  cut  through  it.  The  external 
circumference  of  the  stomach  at  this  part  appeai-ed  to  be  so  small  that 
no  hope  could  be  entertained  of  excising  the  ulcer  completely  without 
leaving  too  great  a  constriction.  Nothing  could,  therefore,  be  done 
except,  by  means  of  sutures  passed  through  the  healthy  tissue,  to  draw 
the  stomach  up  to  the  edge  of  the  abdominal  wound  and  carefully  stitch 
them  together.  The  peritoneal  cavity  was  then  washed  out,  and  the 
lower  part  of  the  abdominal  incision  closed,  leaving  a  gastric  fistula.  After 
the  operation  the  pain  in  the  abdomen  ceased,  she  vomited  only  seldom, 
suffered  little  inconvenience  from  the  wound  beyond  that  due  to  a  very 
profuse  flow  of  highly  acid  gastric  secretion,  which  irritated  the  skin  for 
some  distance  round  it,  and  may  in  some  degree  be  answerable  for  the 
fatal  issue. 

Into  the  further  details  of  this  case  it  is  not  necessary  to  enter.  Suffice 
it  to  say  that  she  rallied  well,  and  continued  to  improve  till  Wednesday, 
when  a  change  for  the  worse  set  in,  and  she  gradually  sank  till  death 
occurred  at  5  50  on  Sunday  morning — just  six  days  after  the  perforation 
had  taken  place.  A  more  unfavourable  site  for  a  perforating  gastric 
ulcer  can  scarcely  be  imagined.  Had  it  been  more  fortunately  situated, 
the  diseased  tissue  could  have  been  easily  excised,  ihe  opening  closed 
with  Lembert's  suture,  and  the  stomach  returned  to  the  abdominal 
cavity. 

From  these  cases  we  may,  I  think,  draw  the  more  usual 
symptoms  of  perforation.  In  only  one  case  was  the  previoi\s 
history  of  any  assistance  to  us  in  arriving  at  a  diagnosis ;  while 
the  other  two  presented  no  symptoms  before  their  illness  which 
could  have  aroused  our  suspicions  of  an  internal  ulcerative  process. 
In  diagnosticating  a  perforation  of  the  stomach,  we  have  to  rely 
mainly  on  the  sudden  onset  of  very  violent  pain,  often  described 
by  the  patient  as  doubling  him  in  two,  the  accompanying  collapse, 


By  Dr.  Alfred  R.  Parsons.  81 

pallor,  and  anxious  expression  of  the  face,  a  pulse  small  in  volume, 
compressible  and  steadily  increasing  in  frequency ;  vomitino;  is  also 
often,  though  not  invariably,  present;  and  the  respiration  will 
probably  be  rapid,  chiefly  thoracic,  and  productive  of  pain  on  deep 
inspiration.  If  we  see  the  patient  a  few  hours  later,  the  severity  of 
the  pain  may  be  slightly  abated,  the  collapse  not  quite  so  marked, 
and  the  colour  improved,  but  the  frequency  of  the  pulse  has  increased 
from  90  or  100  to  110  or  120,  with  probably  diminished  volume 
and  augmented  compressibility.  Visiting  our  patient  some  hours 
later — say  12  or  14  after  the  perforation  has  taken  place — he 
expresses  himself  as  much  better ;  he  has  no  longer  the  intense 
pain  from  which  he  suffered  earlier  in  the  day  ;  there  is  no 
impairment  whatever  of  his  intellectual  faculties;  but,  on  the 
contrary,  he  is  quite  clear  and  collected,  and  looks  to  you  to  eon- 
firm  the  favourable  opinion  he  has  formed  of  his  own  condition. 
But,  as  you  take  his  clammy  hand  in  yours,  and  try  to  count  the 
pulse,  now  barely  perceptible  at  the  wrist,  as  you  feel  the  cold 
extremities,  and  see  the  sweat  gathering  on  the  pallid  countenance, 
you  read  the  words  "  No  hope  I "  written  clearly  on  every  feature. 
The  prognosis  is  soon  equally  evident  to  the  untrained  eye. 
Restlessness  comes  on,  slight  delirium  sets  in,  the  pulse  can  no 
longer  be  felt,  respiration  becomes  quick,  shallow,  irregular,  slow, 
and  finally  ceases,  in  the  majority  of  cases,  in  from  12  to  24  hours 
after  the  perforation  took  place. 

Such  I  take  to  be  a  fairly  typical  history  of  a  case  of  per- 
forative peritonitis,  whether  it  be  left  to  nature  or  treated  as  such 
cases  are  generally  treated.  And  we  have  now  to  ascertain  what 
light  does  the  post-mortem  examination  afford  us?  is  the  pathological 
condition,  if  persistent,  necessarily  followed  by  this  sudden  change 
from  apparent  health  to  death  1  and,  if  so,  are  there  no  means  by 
which  this  condition  can  be  removed  or  modified?  At  the 
autopsy  we  find  a  body  well  developed,  well  nourished  ;  on 
external  inspection  disclosing  nothing  except,  possibly,  some  sliglit 
distension  of  the  abdomen ;  the  brain  and  its  membranes  are 
apparently  perfectly  healthy ;  detailed  examination  of  the  thoracic 
viscera  discloses  no  disease ;  in  the  abdomen  nothing  morbid, 
except  an  acute  diffuse  peritonitis,  evidently  owing  its  origin  to 
an  extravasation  of  the  contents  of  the  stomach  through  a  perfo- 
ration in  its  wall.  Must  we  not^  as  we  stand  by  the  opened  body 
on  the  post-mortem  table,  feel  humiliated  that  lesions  such  as 
these,  situated  not  in  the  pons,  medulla,  internal  capsule,  heart,  or 


32     Susppcted  Perforation  of  Chronic  Ulcer  of  the  Stomach. 

any  other  region  sacred  against  the  intrusion  of  the  surgeon's 
knife,  but  in  tlie  stomach — an  organ  which  in  man  has  been 
incised  frequently,  partly  excised,  and  in  the  lower  animals  com- 
pletely removed  with  success — should  have  been  the  cause  of 
death "?  In  this  the  age  of  gastrectomies,  gastrostomies,  gastro- 
enterostomies, pylorectomies,  are  these  specimens  not  a  reproach 
to  our  diagnostic  skill,  or  operative  courage?  And  must  that 
reproach  not  grow  deeper  as  we  gaze  upon  the  well-built  body, 
not  emaciated  by  prolonged  fever  or  mal-nutrition,  and  examine 
the  remaining  viscera,  not  affected  by  any  trace  of  disease,  and 
fail  to  find  in  all  anything  but  that  small  ulcer  inconsistent  with 
a  prolonged  and  vigorous  life"? 

But,  it  may  be  asked,  is  death,  in  the  absence  of  operative 
measures,  a  necessary  consequence  to  general  peritonitis  produced 
by  the  rupture  of  a  gastric  ulcer  ?  To  this  I  may  briefly  reply — 
Death  is,  in  such  cases,  practically  speaking,  an  inevitable  result. 
I  have  examined  carefully  the  literature  of  this  subject,  and  can 
find  recorded  only  9  cases  which  presented  symptoms  indicative  of 
a  perforation  of  a  gastric  ulcer  and  recovered.  Of  these,  3  died 
subsequently  from  this  affection,  but  in  only  one  of  them  did  the 
posi-wor^emexamination  seem toconfirm  theoriginal  diagnosis.  This 
case  is  reported  by  Hughes,  Ray,  and  Hilton  in  "  Guy's  Hospital 
Reports  "  for  1846  : — "  A  servant  girl  was  suddenly  seized  with  all 
the  symptoms  of  perforation.  Fortunately  she  had  eaten  nothing 
for  four  hours  before  this,  and  then  only  gruel.  She  was  put  under 
the  influence  of  opium,  was  kept  in  the  recumbent  posture,  and 
was  fed  by  the  rectum.  She  was  discharged  apparently  cured 
after  52  days.  Two  months  afterwards  she  was  again  suddenly 
seized  with  the  same  symptoms,  and  she  died  in  four  hours.  The 
autopsy  showed,  in  addition  to  a  recent  peritonitis,  evidence  of 
old  peritonitis.  There  were  adhesions  of  the  coils  of  intestines 
with  each  other,  and  between  the  stomach  and  adjacent  viscera. 
In  the  stomach  were  found  a  cicatrix  and  two  open  ulcers,  one  of 
which  had  perforated." 

Such  a  record  out  of  the  many  fatal  cases  of  gastric  ulcer 
which  have  been  reported  fully  justifies  Mr.  Treves  when  he  says, 
"  The  lover  of  the  curious  will  search  long  before  he  can  find  in 
the  literature  of  perforative  peritonitis  the  account  of  a  well- 
authenticated  recovery  without  operative  interference;"  and 
gives,  for  all  practical  purposes,  a  direct  negative  to  the  inquiry 
in  such  cases — Is  there  any  hope? 


Bv  Dr.  Alfred  R.  Parsons.  33 

If  the  prognosis,  then,  in  these  cases  when  left  to  nature  or  as 
usually  treated  be  hopeless,  can  we  do  nothing  when  called  to  a 
patient  presenting  the  symptoms  I  have  enumerated?  It  seems 
to  me  that  our  duty  under  such  circumstances  is  threefold:  — 
1.  To  avoid  increasing  the  mischief  already  done.  Consequently 
all  food,  medicine,  and  stimulants  by  the  mouth  should  be  strictly 
prohibited.  2.  To  relieve  the  agony  which  the  patient  is  suffering 
by  a  hyjoodermic  of  morphin,  and  to  combat  the  collapse  by  the 
administration  of  stimulants  per  rectum  3.  To  recognise  earhi 
that  the  case  before  us  is  one  imperatively  demanding  immediate 
operative  interference.  This  appears  to  me,  under  such  circum- 
stances, to  be  the  highest  function  of  the  physician's  art,  and 
while  sometimes  the  diagnosis  may  be  quite  evident,  in  others  it 
requires  great  care  to  form,  and  courage  to  express,  such  an 
opinion.  It  is  not  to  be  expected  that  a  physician  should,  as  it 
were,  see  through  the  abdominal  wall  and  accurately  describe  the 
nature  and  seat  of  the  lesion ;  but  ought  he  not  to  recognise  that 
he  has  to  do  with  some  urgent  intra-abdominal  lesion  imperilling 
his  patient's  life,  and  probably  connected  with  the  rupture  of  a 
hollow  viscus,  and  that  the  only  way  in  which  the  diagnosis  can 
be  completed  and  the  patient's  life  saved  is  by  an  exploratory 
laparotomy?  But  the  sceptic  will  probably  ask,  what  has  an 
abdominal  section  ever  done  for  perforative  peritonitis  due  to 
rupture  of  a  gastric  ulcer  f  I  regret  I  can  only  point  to  a  life 
prolonged  a  few  days  and  to  a  less  painful  death  in  the  cases  I 
record  in  this  paper ;  and  I  am  free  to  admit  that  I  have  searched 
the  literature  of  this  question  without  finding  one  successful  case. 
The  explanation  of  this,  I  believe,  is  not  far  to  seek.  But  first 
let  me  briefly  mention  what  has  been  done  in  conditions  somewhat 
resembling  those  under  consideration. 

In  "  St.  Bartholomew's  Hospital  Reports  "  for  1873,  Mr.  Thomas 
Smith  gives  an  account  of  several  cases  of  general  peritonitis  con- 
sequent on  rupture  of  an  ovarian  cyst  in  which  he  opei'ated  suc- 
cessfully. Professor  Kocher  did  a  laparotomy  three  hours  after 
the  receipt  of  a  pistol-shot  wound  of  the  stomach,  closed  it  with 
sutures,  and  the  patient  recovered  completely.  Dr.  Ball's  suc- 
cessful case  of  a  boy,  who  received  a  stab  in  the  abdominal  wall 
penetrating  the  stomach,  in  which,  four  hours  after  the  injury, 
he  did  a  laparotomy,  and  stitched  the  edges  of  the  wound  together, 
will  be  in  the  recollection  of  some  members  of  the  Section.  In  a 
paper  read  before  the  Medico-Chirurgical  Society  of  London  in 

D 


34     Suspected  Perforation  of  Chronic  Ulcer  of  the  Stoniach. 

I880,  Mr.  Treves  described  a  case  of  acute  general  purulent  peri- 
tonitis due  to  the  bursting  of  a  pelvic  abscess  into  the  abdominal 
cavity,  in  which  he  opened  the  abdomen,  flushed  out  the  cavity, 
and  put  in  a  drainage-tube  with  the  most  satisfactory  results. 
Several  cases  of  successful  laparotomies  for  general  peritonitis 
secondary  to  perforation  of  the  vermiform  appendix  have  been 
recorded;  and  lastly,  from  Dr.  J.  W.  Moore's  recent  work  on  the 
"  Continued  and  Eruptive  Fevers,"  I  learn  that  of  1 9  attempted 
laparotomies  for  perforation  in  typhoid  fever,  4  were  successful. 
Handicapped  as  the  operators  in  these  latter  cases  must  have 
been  by  extensive  ulceration  and  inflammation  of  the  intestine, 
by  high  fever — by,  in  fact,  almost  every  condition  that  could  mili- 
tate against  satisfactory  union  — such  results  were  brilliant.  Why 
have  the  cases  of  gastric  perforation  in  the  past  not  been  equally 
successful "?  Chiefly  because  they  have  been  done  too  late.  They 
have  been,  in  many  cases,  1  fear,  postponed  hour  by  hour  till  the 
diagnosis  was  absolutely  certain,  and  the  patient  almost  moribund, 
lest  it  might  be  said,  ''  The  abdomen  was  opened  and  nothing 
found ;  "  while  in  typhoid  fever  the  onset  of  peritonitic  symptoms 
was  more  or  less  expected,  and  no  time  was  lost  in  deciding  as  to 
the  advisableness  of  operating. 

Two  courses  are  open  to  us  in  treating  cases  of  suspected  per- 
foration. We  may  reject  operative  interference,  take  our  stand 
on  the  traditions  hallowed  by  time  and  authority,  and  follow 
Heister,  who,  writing  in  1739  on  perforation  of  the  bowel,  could 
only  advise  that  the  patient  be  kept  quiet,  that  he  be  urged  to 
eat  abstemiously,  and  to  lie  upon  his  belly,  and  that  the  rest  be 
left  to  Divine  Providence  and  the  strength  of  the  constitution ; 
or,  mindful  of  the  recent  great  advances  in  abdominal  surgery,  of 
the  very  slight  risk  attending  an  exploratory  laparotomy,  of  the 
fatal  consequences  of  a  perforation  when  left  alone,  we  may  make 
up  our  minds  early  that  the  case  calls  for  an  abdominal  section. 

In  1881  Dr.  Marion  Sims,  when  addressing  a  medical  society 
in  America,  having  described  the  sudden  death  of  an  eminent 
physician  in  six  hours  from  intestinal  perforation,  and  recom- 
mended opening  the  abdomen  and  stitching  up  the  wound, 
said — "  Rest  assured  that  the  day  will  come,  and  it  is  not  far  off', 
when  an  accurate  diagnosis  in  such  cases,  followed  by  prompt 
action,  will  save  life  that  must  otherwise  quickly  ebb  away."  If 
that  day  is  hastened  in  any  degree  by  any  statements  I  have 
made  in  this  paper — if  I  have  persuaded  any  of  my  audience  to 


Not'.t  on  Epirpmic  fnjln<>nza,  1801-92.  3i 

arlfl  acute  perforative  peritonitis  to  the  generally-admitted  four 
great  surgical  emergencies  requiring  immediate  operative  inter- 
ference, my  object  in  virriting  this  paper  is  gained. 

Mr.  President  and  Gentlemen,  I  must  apologise  for  the  trial  to 
vi^hich  I  have  subjected  you  with  these  rambling  thoughts  and 
quotations,  and  express  my  gratitude  to  you  for  the  patience  with 
which  you  have  listened  to  me.  The  matter  and  manner  of  the 
communication  are  far  from  what  I  would  wish  them  to  be.  The 
only  excuse  I  can  offer  is,  that  as  I  stood  by  the  bedside  of  some 
of  these  patients,  and  saw  the  vital  tide  fast  ebbing  away,  if  one 
thought  were  impressed  upon  me  more  than  another  it  was,  "  To 
save  such  cases  one  must  open  the  abdomen  and  open  it  early." 


Art.  IV. — Notes  on  Epidemic  Influenza,  1891-92.  By  E. 
MacDowel  Cosgrave,  M.D.,  F.R.C.P.I. ;  Physician  to  Whit- 
worth  Hospital,  Drumcondra,  and  Cork-street  Fever  Hospital ; 
Professor  of  Biology,  Royal  College  of  Surgeons. 

The  epidemic  of  influenza  in  1891-92  presented  several  peculia- 
rities not  observed  in  1889-90  or  1890-91.  The  outbreak  was 
more  sudden  and  widespread,  the  catarrhal  symptoms  more  want- 
ing, and  the  cases  ran  an  acuter  course,  whether  ending  in  recover^' 
or  death. 

Having  met  with  a  large  number  of  cases  which  ran  their 
course  unmasked  by  complications,  I  have  noted  down  some  of  the 
points  which  appeared  of  most  interest,  as  a  slight  contribution  to 
the  history  of  the  epidemic. 

The  cases  occurred  practically  in  the  course  of  four  months — 
November  and  December,  1891,  and  January  and  February, 
1892 — but  the  epidemic  virulence  lasted  only  some  two  months. 
Cases  were  sporadic  in  November,  but  a  pandemic  outburst 
occurred  in  the  second  week  in  December,  the  decline  of  intensity 
and  return  to  sporadic  eases  taking  place  in  the  second  week  in 
February. 

The  lengthened  period  of  time  during  which  sporadic  cases 
occurred  harmonises  with  the  opinion  I  have  long  held,  that  infec- 
tion in  influenza  epidemics  is  confined  to  an  area  of  epidemic 
influence,  which  includes  the  district  in  which  the  epidemic  is 
active  and  a  more  or  less  extended  zone  outside  it — that  is  to  say, 
that  although  epidemic  influenza  spreads  by  contagion,  the  conta- 
gion is  chiefly  active  in,  or  close  to,  the  area  of  marked  epidemic 


36  Notes  on  Epidemic  Injluenza^  1891-92. 

influence,  so  that  whilst  an  infected  person  going  to  a  district 
well  outside  the  zone  of  the  epidemic  is  unlikely  to  establish  the 
disease,  an  infected  person  going  to  a  district  close  to  that  already 
affected  is  likely  to  prove  a  fresh  centre  of  infection.  The  course 
of  the  epidemic  across  the  Continent  of  Europe  to  England  and 
to  Ireland,  so  very  slow  compared  with  the  transit  of  passengers 
and  goods,  is  thus  reconciled  with  the  fact  of  its  contagiousness — 
two  characteristics  which,  at  first  sight,  appear  inconsistent. 

This  can  be  illustrated  by  two  typical  cases.  The  first  case  I 
saw  in  November.  He  was  a  boarder  in  a  large  school  and  came 
into  Dublin  to  spend  a  half-holiday  with  some  friends.  As  he 
complained  of  pains  and  shivered  over  the  fire,  I  was  asked  to  see 
him,  and,  recognising  what  he  was  suffering  from,  recommended 
that  he  should  be  kept  in  town.  He  did  not  return  to  school  for 
two  weeks.  There  was  no  outbreak  in  the  school,  and  the  disease 
was  not  communicated  to  anyone  in  the  house  he  stayed  in. 

The  second  case,  or  rather  series  of  cases,  occurred  in  the  second 
week  in  December,  when  the  epidemic  influence  was  fully  deve- 
loped, and  were  partly  in  the  house  where  the  former  case  had 
been  nursed.  A  young  lady  was  taken  ill  with  influenza  on  the 
9th ;  a  friend  who  had  helped  to  nurse  the  former  case  was  spend- 
ing the  day  with  her  and  developed  it  on  the  11th;  a  married 
sister  nursed  her  and  got  it  on  the  15th  ;  the  parents  of  the  young 
lady  and  a  servant  also  took  it,  as  did  the  husband  of  the  married 
sister,  and  a  visitor  staying  in  the  house.  Eight  people  developed 
it  in  this  series,  the  average  period  of  incubation  being  two  days. 

These  cases  are  only  given  as  types.  Amongst  the  cases 
observed  before  the  second  week  in  December  there  seemed  no 
tendency  to  spread ;  once  the  epidemic  was  established,  when  a 
case  occurred  it  appeared  almost  certain  to  spread.  The  pandemic 
area  and  the  sporadic  area  may  be  compared  to  the  shadow  and 
penumbra. 

The  class  affected  by  the  epidemic  is  a  point  of  great  interest. 
Those  who  lived  in  overcrowded  dwellings,  and  suffered  from 
exposure  and  want  of  food,  seemed  less  likely  to  be  affected  than 
the  well-to-do  classes ;  and  those  comfortably  off,  but  living  in 
small  houses,  seemed  to  be  not  as  much  affected  as  the  richer 
classes. 

Amongst  the  predisposing  causes  great  fatigue  seemed  the  most 
potent.  I  noticed  this  in  my  own  case  and  in  the  case  of  other 
medical  men,  who  attended  numerous  cases  day  after  day  with 


By  Dr.  E.  MacDowel  Cosgrave.  37 

apparent  impunity,  but  suddenly  developed  symptoms  of  the  dis- 
ease from  12  to  24  hours  after  a  specially  fatiguing  day's  work. 

There  were  two  classes  of  cases  running  respectively  a  course  of 
3-4  days  and  7-8  days.  This  is  similar  to  what  is  seen  in  other 
fevers — the  third  week  that  typhus  sometimes  runs,  the  fourth 
and  subsequent  weeks'  illness  so  frequent  in  enteric  fever. 

JThere  were  five  chief  prominent  symptoms  amongst  my  uncom- 
plicated cases ;  sometimes  they  occurred  singly,  but  generally  two 
or  more  were  present.  Only  the  cases  in  which  they  were  well 
marked  are  counted. 

1.  Bronchial  catarrh.  This  was  the  most  frequent,  being  promi- 
nent in  62  per  cent,  of  my  cases.  Sometimes  it  was  accompanied 
by  distressing  bronchorrhoea,  sometimes  by  a  medium  or  slight 
amount  of  viscid,  tenacious  mucus ;  in  no  case  was  it  "  dry." 

2.  Gastro-intestinal  symptoms  were  prominent  in  52  per  cent. 
These  generally  developed  very  rapidly,  vomiting  and  purging 
occurring  within  an  hour  of  the  first  onset ;  vomiting  was  more 
frequent  than  diarrhoea.  This  symptom  generally  lasted  for  the 
3-4  or  7-8  days,  and  for  some  time  afterward  there  was  a  sensa- 
tion when  coughing  of  impending  emesis. 

3.  Rheumatoid  pains  occurred  in  50  per  cent.,  generally  in  the 
back  (all  down  the  spine  and  extending  bilaterally),  sometimes  only 
in  the  legs,  in  which  case  they  were  accompanied  with  great  weak- 
ness of  the  knee  and  ankle. 

4.  Headache  was  a  marked  feature  in  25  per  cent. ;  it  generally 
occurred  in  the  gastric  cases. 

5.  Urinary  symptoms  were  prominent  in  4  per  cent. 

In  19  per  cent,  of  my  cases  no  symptom  except  the  fever  was 
prominent;  in  31  per  cent,  there  were  only  fever  and  bronchial 
catarrh. 

Slow  recovery  to  strength  was  a  marked  feature  of  the  disease. 

None  of  the  cases  ended  fatally ;  indeed,  I  was  fortunate  enough 
not  to  lose  any  of  my  complicated  cases. 

The  treatment  adopted  may  be  briefly  summarised : — 

1.  In  cases  where  the  increased  temperature  was  the  prominent 
symptom,  diaphoretics  were  given.  These  generally  gave  relief, 
and,  I  believe,  shortened  the  attack. 

2.  When  the  rheumatoid  pains  were  severe,  salicylate  of  sodium 
was  given,  antipyrin  being  added  if  the  pain  was  excessive ;  when 
there  was  headache  in  addition  these  were  combined  with  citrate 
of  carfein.     The  relative  proportions  usually  prescribed  were : — 


38  Notes  on  Epidemic  Influenza,  1891-92. 

^.  Salicylate  of  sodium,  1  drachm ; 
Antipyrin,  20  grains ; 

Granular  effervescing  citrate  of  caffein,  1  ounce. 
A  fourth  part  to  be  taken  three  times  during  the  day,  and  the 
fourth  part  on  the  following  morning. 

This  always  gave  relief  ;  sometimes  the  relief  was  almost  imme- 
diate. If  the  pains  returned  a  renewal  of  the  mixture  generally 
dispelled  them  finally. 

3.  In  gastro-intestinal  cases,  hot  milk  and  soda-water  every 
three  hours  was  relied  on  ;  if  there  was  headache,  citrate  of  caffein 
was  given. 

In  no  case  did  I  consider  it  necessary  to  give  alcoholic  stimulants 
(although  the  onset  of  the  disease  was  often  marked  by  extreme 
weakness  of  the  circulation),  and  I  found  the  high  temperature 
did  not  last  so  long,  and  that  the  fall  below  normal,  so  marked  and 
sometimes  so  long  continued  when  alcohol  is  administered,  was 
escaped.  There  was  consequently  not  the  same  depression  of 
spirits  during  early  convalescence,  and  a  healthy  appetite  soon 
returned. 


TEEATMENT  OF  TUBEKCULOSIS  BY  IODOFORM  INDNCTIONS. 

Dr.  Lawrence  F.  Flick,  after  a  year's  experience,  reports  {Medical 
News  of  Philadelphia,  12th  March,  1892)  : — "  Iodoform  will  cure  tubercu- 
losis in  the  first  stage,  and  it  acts  better  when  administered  by  inunctions 
than  when  given  by  the  mouth.  When  the  disease  has  advanced  to  the 
second  or  third  stage  iodoform  may  do  good,  but  can  no  longer  be  depended 
upon  as  a  curative  agent.  As  I  stated  in  my  former  paper,  creasote 
should  then  be  given  together  with  iodoform,  and  given  in  large  doses. 
If  given  diluted  with  hot  water,  as  much  as  fifteen  drops  can  be  taken 
with  comfort.  It  seems  to  me,  indeed,  that  creasote  is  the  drug  to  be 
relied  upon  in  the  second  and  third  stages  of  the  disease.  I,  however, 
use  the  iodoform  inunctions  in  this  stage  for  the  reason  that  the  tubercu- 
lous nodules  in  a  given  case  do  not  all  break  down  at  the  same  time,  and 
that  whilst  some  nodules  may  be  broken  down,  or  have  ah-eady  broken  down, 
there  may  be  many  that  are  still  in  the  first  stage.  Along  with  specific 
treatment  I  always  use  tonics  and  forced  nutrition.  Much  of  the  success 
that  I  ascribe  to  specific  treatment  may  of  course  be  due  to  the  tonic  and 
nutrient  treatment,  but  I  am  bound  to  say  that  my  results  with  iodoform 
inunctions  and  creasote  together  with  tonic  and  nutrient  treatment  are 
much  better  than  they  were  before  I  used  the  inunctions." 


LINTINE. 


PATENTED     JULY      14tm,      1891. 


A  NEW  ABSORBENT  COTTON 

Made  of  Felted  Absorbent  Cotton  Fibres  in  thin  stieets. 

More  Absorbent  than  Cotton   Wool  or  Lint,  and  a  substitute 
for  both  for  all  purposes. 

EVERY  FIBRE  THOROUGHLY  CLEANSED,  STERILIZED  &  ANTISEPTIC 

SOME     ADVANTAGES. 

NO    WASTE. 

TEARS    READILY. 

CLEANLY    AND    COMPACT. 

FIFTY    PER    CENT.    MORE    SURFACE 

THAN    COTTON    OR    LINT. 

NO    LOOSE    FIBRES    TO    STICK    TO 

WOUNDS    OR    CLOTHING. 
SUBSTITUTE    FOR- 

GAUZE,    LINT,    NAPKINS, 

SPONGES,    SHEETS,    SWABS, 
COTTON,    BANDAGES,    TOWELS, 

CLOTHS,    FILTER    PAPER, 

WOOL,    PAPER,    &c. 


AN    IMPROVED    WOUND    DRESSING. 

Readily  shaped  into  Bandages,  Pads,  Tampons,  Cubbiions,  or  any  desired  form 
of  dressing,  for  covering  bedding  and  tables  during  operations,  and  is  superior  to 
towels,  napkins,  or  sheets.  Can  readily  be  formed  into  a  pencil  or  mop  for  throat 
applications,  small  surfaces,  or  cavities.  Perfect  tor  absorbing  discharges,  and  for 
drainage  tubes.  Makes  cheap  and  excellent  Sanitary  napkins,  handkerchiefs  for 
consumptives,  or  diaper  cloths  for  children. 

"  LINTINE"  has  a  thousand  more  uses  :  it  is  better  than  loose  cotton  or  lint, 
and  much  cheaper. 

SAMPLES    SENT    ON    APPLICATION    TO 

JOHNSON   &  JOHNSON,    Ltd., 

1  &  2,  AUSTRALIAN  AVENUE,  LONDON,  E.G. 


JOHNSON  &  JOHNSON,  Ltd., 

Medicinal    Plasters,    Antiseptic    Dressings,    dc. 


SURGEONS'  RUBBER  ADHESIVE  PLASTERS 

On  Silk,  Twill  Cotton  Cloth,  Twilled  Linen,  Moleskin, 
Felt  (for  splints,  bed  sores,  &c.),  in  i  yard  and  5  yard  rolls. 
Also   on    reels    10   yards    x    V    i,    li,    2,    2I,    3   inches  wide. 
Plain  or  Porous. 


b 

S( 

u 


/ 


OUR   NEW  GAUZE  l^riN 

Allows  the  Gauze  to  be  withdrawn  as  requyred  without  removing 

the  roll.  \^ 

It  also  prevents  drying  and  deterioration.    ;d 

MOIST  ANTISEPTIC   ofcalESSINGS. 

Perfectly  sterilised,  containing  an  exa^^  Measure  of  antiseptic 

drug,  thoroughly  and  evenly  distributed/*'  "^"Id  in  the  dressing 

,    ,.  *sniteen  c 

in  solution.  ^ 

Absorptive  and  Moist,  Soft  and  Pliable,  will  ^ig^t  change  by  age. 

Always  ready  for  use,  always  reliable.  1 

Our  list    of  Moist  Antiseptic  Dressings    inclut-des    Cotton    and 

Gauzes,  Oakum  and  Jute,  Medicated  with  all  An]tiseptics  desired. 


Pamphlet,    "  Modern      Methods     of    Antisl(eptic     Wound 
Treatment"  sent  on  application  thO 

JOHNSON    &    JOHNSOr'vl,  Ltd., 

1  &  2,  AUSTRALIAN  AVENUE,  LONDOl  ^,  E.G. 


PART  II. 

REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


Bacteriological  Diagnosis:  Tabular  Aids  for  Use  in  Practical 
Work.  By  James  Eisenberg,  Ph.D.,  M.D.  Translated  and 
augumented,  with  the  permission  of  the  Author,  from  the 
Second  German  Edition,  by  Norval.  H.  Pierce,  M.D. 
Philadelphia  and  London  :  F.  A.  Davis  Co.     1892.     Pp.  184. 

It  is  somewhat  unfortunate  that  this  translation  of  the  second 
edition  of  Dr.  Eisenberg's  well-kno\vn  tables  should  appear  almost 
simultaneously  with  a  third  and  greatly  enlarged  edition  of  the 
original.  Still  there  can  be  no  doubt  that  the  translation  will  be 
welcome  to  those  bacteriological  workers  who  do  not  read  German, 
a  happily  diminishing  class. 

The  organisms  described  are  138  in  number,  and  are  divided 
into — I.  Non-pathogenic  bacteria ;  {a)  liquefying  gelatine ;  (6)  not 
liquefying  gelatine.  II.  Pathogenic  bacteria  ;  (a)  cultivated  out- 
side the  body ;  (6)  not  cultivated  outside  the  body.  III.  Fungi. 
The  descriptions  are  given  in  the  form  of  tables  under  the  follow- 
ing headings  for  bacteria  : — Place  found ;  form  and  arrangement  ^ 
motility ;  growth  on  gelatine,  agar,  potatoes,  blood-serum  ;  tem- 
perature at  which  growth  occurs ;  rapidity  of  growth ;  spore 
formation  ;  aerobiosis ;  gas  production ;  gelatine  reaction  ;  colour 
production  ;  aniline  reaction ;  pathogenesis. 

In  the  case  of  the  fungi  the  headings  are  different  and  as 
follows : — Place  found  ;  colour  of  growth ;  mycel  arrangement ; 
f ructificative  organs ;  growth ;  temperature ;  examination  methods ; 
pathogenesis. 

At  the  head  of  many  of  the  tables  references  are  given  to  the 
most  important  papers  on  the  organisms  in  question. 

It  will  be  seen  that  the  arrangement  is  most  convenient ;  and 
the  great  popularity  enjoyed  by  the  work  will  be  readily  under- 
stood. In  fact  it  is  a  work  which  can  scarcely  be  dispensed  with 
by  any  practical  bacteriologist.  On  the  whole,  the  translator 
seems  to  have  doue  his  work  fairly  well.     Some  of  his  additions 


40  Revietcs  and  Bibliographical  Notices. 

are,  however,  not  very  fortunate — as,  for  example,  the  table  in 
which  the  organism  of  scarlatina  described  by  Klein  is  confounded 
with  that  described  by  Edington.  There  is  not  much  room  for 
style  in  translating  such  a  work  as  this;  but  the  very  first 
sentence,  describing  the  first  organism.  Bacillus  prodigiosus,  is  in 
want  of  improvement.  "  Most  probably  it  settles  from  the  air  on 
to  the  nourishing  material ;  but,  up  to  the  present,  they  have  not 
been  demonstrated  in  the  air." 

In  an  appendix  a  very  good  description  is  given  of  the  methods 
used  in  the  cultivation  and  staining  of  micro-organisms.  The 
volume  concludes  with  an  excellent  index. 


The  Principles  and  Practice  of  Medicine,  designed  for  the  use  of 
Practitioners  and  Students  of  Medicine.  By  William  Osler, 
M.D.,  F.K.C.P.,  Professor  of  Medicine  in  the  Johns  Hopkins 
University ;  Physician-in-Chief  to  the  Johns  Hopkins  Hospital, 
Baltimore  ;  formerly  Professor  of  the  Institutes  of  Medicine, 
M'Gill  University,  Montreal ;  Professor  of  Clinical  Medicine 
in  the  University  of  Pennsylvania.  Edinburgh  and  London  : 
Young  J.  Pentland.     1892.     Pp.  1,079. 

Anything  from  the  pen  of  Prof.  Osier  necessarily  raises  great 
expectations  in  our  mind,  and  it  was  with  the  feeling  that  there  was 
something  good  in  store  for  us  that  we  undertook  the  perusal  of  his 
latest  work.  Having  carefully  examined  the  book,  our  verdict  is 
that  it  is  one  of  the  best  text-books  of  medicine  that  it  has  been 
our  good  fortune  to  meet. 

This  handsome  and  well-printed  volume  is  no  mere  compilation 
of  extracts  taken  from  older  works.  On  every  page  we  find  the 
author's  personal  experience  and  opinions,  not  dogmatically  laid 
down,  but  clearly  put  forward  in  conjunction  with  other  and 
opposing  views.  One  of  the  circumstances  that  introduces  into 
this  book  something  of  novelty  and  freshness  for  a  British  reader, 
is  the  fact  that  every  subject  is  looked  at  from  an  American  point 
of  view ;  American  authorities  and  statistics  are  quoted ;  American 
epidemics  and  health-resorts  are  mentioned  ;  and  one  or  two  diseases 
are  described  which,  as  far  as  is  known,  have  been  observed  only 
in  America. 

The  general  arrangement  of  this  work  is  much  the  same  as  that 
found  in  other  works  on  medicine.  The  chief  novelty  in  arrange- 
ment is  that  diseases  caused  by  animal  parasites — psorospernis, 


OSLER — Principles  and  Practice  of  Medicine.  41 

intestinal  worms,  parasitic  insects,  &c. — are  included  in  a  section 
by  themselves.  If  this  method  of  classification  were  fully  carried 
out,  there  ought  to  be  another  class  of  diseases  caused  by  vegetable 
parasites ;  for  this,  however,  in  the  absence  of  any  knowledge  as  to 
the  exciting  cause  of  the  exanthemata  and  other  specific  fevers, 
the  time  has  probably  not  yet  come. 

Many  of  the  articles  are  really  first-class.  The  work  opens  with 
an  admirable  account  of  typhoid  fever,  which  occupies  about  38 
pages.  We  read  with  interest  that  the  first  physician  who  clearly 
laid  down  the  difference  between  typhoid  and  t^^hus  was  Dr. 
Gerhard  of  Philadelphia.  "  His  papers  in  the  American  Journal 
of  the  Medical  Sciences,"  says  Osier,  "  are  undoubtedly  the  first 
in  any  language  which  give  a  full  and  satisfactory  account  of  the 
clinical  and  anatomical  distinctions  which  we  now  recognise." 
With  regard  to  that  much-debated  subject,  the  treatment  of 
typhoid.  Osier  seems  to  favour  a  rigid  system  of  hydrotherapy, 
and  bathes  a  patient  every  three  hours  if  his  temperature  is  above 
102*5°  F.  Intestinal  antiseptics  he  thinks  useless,  but  harmless. 
Tuberculosis  is  treated  as  a  whole,  and  instead  of  finding  phthisis 
among  diseases  of  the  lungs,  tubercular  meningitis  among  nervous 
diseases,  &c.,  we  find  one  chapter  describing  every  form  of  tubercular 
affection,  and  occupying  72  pages.  This  plan  is  a  good  one,  and 
avoids  the  necessity  of  much  repetition.  While,  however,  typhoid, 
tuberculosis,  pneumonia,  and  other  diseases  are  described  in  a  truly 
admirable  manner,  some  aft'ections  do  not  in  our  opinion  get  any- 
thing like  the  attention  they  deserve.  There  is  no  disease  more 
common  or  more  important  to  the  medical  man  than  bronchitis  ; 
we  find,  however,  that  acute  bronchitis  occupies  only  two  pages  and 
a  half,  and  chronic  bronchitis  two  and  three  quarters.  Again, 
chorea  occupies  12  pages,  while  only  one  and  a  half  are  allotted  to 
insular  sclerosis,  two  to  migraine,  and  two  and  a  half  to  tetanus. 
Such  inequalities  are  much  to  be  regretted.  It  appears  to  us  a 
very  serious  omission  that  there  is  no  introduction  to  several 
of  the  sections  on  clinical  pathology  and  modes  of  examination. 
For  students  the  work  is  seriously  diminished  in  value  by  the  fact 
that  there  is  no  classification  or  explanation  given  of  the  morbid 
sounds  and  other  phenomena  in  the  lungs ;  we  are  plunged  at  once 
into  rales  and  tubular  breathing,  and  are  not  told  how  these 
phenomena  are  produced,  or  what  is  their  clinical  importance. 
Again,  we  think  there  should  have  been  an  introductory  chapter 
to  the  section  on  diseases  of  the  nervous  system,  in  which  there 


42  Reviews  and  Bibliographical  Notices. 

might  be  an  account  of  reflexes,  spasm,  incoordination,  and  other 
matters  of  clinical  importance  connected  with  the  pathology  of  the 
nervous  system.  These  omissions  are  the  more  inexplicable,  as 
there  is  a  chapter  on  the  methods  of  clinical  examination  of  the 
stomach  :  Ewald's  Probefriihstuck,  Tropasolin  00,  &c.  We 
regret,  too,  that  there  are  not  a  few  more  illustrations  in  the  book. 
Excluding  temperature  charts  there  are  only  five  diagrams,  all  of 
which  relate  to  the  nervous  system.  Illustrations  of  urinary  sedi- 
ments, of  the  various  system-degenerations  in  the  spinal  cord,  and 
of  similar  objects,  would  not  have  greatly  increased  the  size  or  cost 
of  the  work,  and  would  have  rendered  it  more  useful.  For  our  own 
part,  we  do  not  see  why  books  on  practice  of  medicine  are  not  much 
more  fully  illustrated  than  they  usually  are.  Works  on  surgery 
contain  woodcuts  of  most  of  the  diseases  and  morbid  conditions 
that  they  refer  to,  but  half  a  dozen  diagrams  are  thought  sufficient 
for  many  large  and  important  works  on  medicine.  These  things 
ouffht  not  so  to  be. 

As  might  be  expected  in  Prof.  Osier's  work,  the  most  recent 
views  on  pathology  are  mentioned :  Laveran's  plasmodium  malarije, 
Eberth's  bacillus  of  typhoid,  Loffler's  diphtheria  bacillus  are  suffi- 
ciently mentioned.  Rare  and  recently  described  diseases — such  as 
Weil's  disease,  Malta  fever,  and  Thomson's  disease—  are  not  over- 
looked. The  index  of  contents  deserves  tlie  greatest  praise  ;  it  is 
unusually  full  and  accurate. 

If  we  have  called  attention  to  what  seem  to  us  to  be  defects  in 
this  work,  we  have  done  so  in  no  hostile  spirit.  On  the  contrary, 
we  have  formed  an  exceedingly  high  opinion  of  its  merits  and 
excellences,  and  consider  it  one  of  the  best  works  on  the  practice 
of  medicine  that  has  appeared  in  the  English  language. 


Royal  University  of  Ireland.      The   Calendar  for  the    Year  1892. 

Dublin  :  Alex.  Thom  &  Co.     1892.     8vo.     Pp.  390. 
Royal  University  of  Ireland.     Examination  Papers,  1891.     Dublin : 

Alex.  Thom  &  Co.     London  :  Longmans,  Green  &  Co.     1892. 

8vo.     Pp.  445  and  113. 
These  useful  guides  to  the  Students  of  the  Royal  TTniversity  of 
Ireland  have  been  published  in  the  usual  first-class  manner. 

The  only  important  change  in  the  subjects  of  Examination  in 
the  Faculty  of  Medicine  for  1893  is  the  transference  of  Pharma- 
cology (Materia  Medica)  from  the  second  to  the  third  Professional 


BallancE — Ligation  of  the  Great  Arteries  in  Continuity.     43 

Examination.  Notice  also  is  given  that,  in  order  to  carr^-  out 
the  regulations  of  the  General  Medical  Council  under  the  Five 
Years'  Scheme,  the  prescribed  courses  will  be  amended  and 
"will  be  pubHshed  during  the  cmrent  year"  (page  173). 

The  Examination  Papers  set  in  1891  are,  as  usual,  pubhshed 
as  a  supplement  to  the  University  Calendar  in  a  separate  volume. 
From  the  niunbering  of  the  pages,  the  Examinations  in  the  Art^s 
Faculty  appear  to  be  printed  separately  from  those  in  the  Pro- 
fessional Faculties  of  Engineering,  Law,  ^ledicine  and  Music. 
This  is,  in  our  opinion,  a  good  plan. 

We  notice  with  some  siu^rise  that  in  both  volumes  a  very 
significant  prominence  is  given  to  a  long  advertisement  of  the 
"CathoHc  University  Medical  School."  One  would  suppose 
that  this  institution  was  the  recognised  School  of  the  Royal 
University. 


A    Treatise  on  the  Ligation  of  the   Great  Arteries  in  Cotitiniiity, 

with    Observation   on   the  Nature,    Progress,   and    Treatment    of 

A  neurism.     By  Charles  A.  Ballance,  M.S.,  &c.,  and  Walter 

Edmunds,  M.C,  &c.     Illustrated  by  10  plates  and  232  figures. 

London  and  New  York:   Macmillan  &  Co.     1891.     Royal  8vo. 

Pp.  568. 

In  this  work,  which  is  produced  in  the  most  luxurious  style  as 

regards  paper,  type,  illustrations,  and  binding,  making  it  a  pleasure 

to  read,  we  find  embodied  the  results  of  the  researches  in  which 

the  authors  have  been  engaged  over  a  number  of  years,  and  to 

which  partial  publicity  had  already  been  given  in   the  Medico- 

Chirurgical  Transactions,   and  in  the   Erasmus  W^ilson   Lectures 

in  1889.     Here,  however,   the  whole   subject   of  the  ligature  of 

vessels,  embracing  the  pathology  of  hemorrhage  and  the  process 

of  repair,  is  fully  dealt  with,  and  the  work  as  a  whole  constitutes 

the  most  complete  monograph  which  exists  on  the  subject  in  any 

language. 

A  very  interesting  chapter  deals  with  the  "  Nature  of  Arteries," 
in  which  their  minute  structure  is  carefully  examined,  and  the 
relative  thickness  of  their  tunics  accurately  measured  and  tabu- 
lated, one  of  the  most  important  facts  established  being  the  extreme 
thinness  of  the  walls  of  a  healthy  artery  in  its  natural  state. 
"  Pliysiolosical  Occlusion  "  is  fullv  treated  of,  the  obliter.ition  of 
the  ductus  arteriosus    being   taken   as   a    type ;    followed   by   au 


44  Reviews  and  Bibliographical  Notices, 

exhaustive  review  of  the  subject  from  a  pathological  standpoint. 
The  chapters  on  the  "  Conduct  and  Fate  of  the  Corpuscles " 
and  the  "  Conduct  and  Fate  of  the  Clot "  are  enriched  with  the 
details  of  many  experiments,  and  illustrated  with  some  beautiful 
plates.  The  use  of  the  corpuscles  and  fibrin  of  the  clot  is  shown 
to  be  a  threefold  one — they  act  as  a  barrier  to  the  current  of  the 
blood  ;  they  form  a  ladder,  or  network,  by  which  the  repairing 
cells  gain  entrance  ;  and  when  they  die  they  serve  as  nutriment 
for  the  plasma  cells  derived  from  the  intima  of  the  vessel. 

In  the  process  of  repair  the  corpuscular  elements  take  no  part. 
"  The  scar-tissue,  which  occludes  the  artery,  is  formed,  not  from  the 
leucocytes  of  the  blood,  but  from  the  plasma-cells  of  the  arterial 
wall."  And  to  accomplish  this  occlusion  rupture  of  the  coats  of 
the  vessel  is  not  necessary.  As  a  result  of  their  study  of  physio- 
logical occlusion  the  authors  sum  up  their  views  as  follows  : —  "  In 
conclusion,  it  may  be  pointed  out  to  the  followers  of  J.  F.  D.  Jones, 
that  Nature  does  not  think  it  necessary,  when  occluding  the  ductus, 
to  rupture  the  two  inner  coats  in  order  to  produce  sufficient  intimal 
growth ;  and  to  the  followers  of  Celsus  and  Abernethy,  that  she 
does  not  divide  the  artery  to  reduce  the  longitudinal  tension — on 
the  contrary,  she  does  not  hesitate  greatly  to  increase  it ;  never- 
theless, in  her  hands,  failure  to  occlude  very  rarely  occurs,  hemor- 
rhage {sic)  never"  (p.  78).  Most  interesting  are  the  experiments 
in  the  Ziegler  chambers,  and  the  light  they  throw  on  the  pro- 
cess of  clot-formation.  The  formation  of  the  fibrin  trabeculaB 
radiating  from  a  fibrin  node,  presumably  the  seat  of  disintegration 
of  a  blood-platelet,  and  the  subsequent  inroad  of  the  plasma  cells 
along  these  guide-lines  were  clearly  seen,  and  identical  processes 
afterwards  observed  in  arteries  at  various  periods  after  ligature, 
and  in  this  connection  we  think  the  authors  have  made  a  good 
case  for  their  opinion  "  that  the  primary  cellular  invasion,  the  solid 
cylinders  of  cells,  and,  later,  the  capillaries,  all  occupy  the  place 
once  held  by  the  bands  of  fibrin  which  stretch  from  node  to  node  " 
(p.  173).  But  we  must  pass  over  many  other  interesting  physio- 
logical questions  which  are  fully  entered  into  and  discussed  in 
these  chapters. 

Most  interesting,  also,  are  those  portions  dealing  with  the 
changes  which  the  coats  of  the  vessel  undergo,  and  also  the  fate 
of  aseptic  ligatures.  It  will  astonish  many  to  learn  that  the  only 
ligatures  that  remain  permanently  encapsuled  and  unabsorbed  are 
those  of  gold  and  of  platinum.     "  Wires  of  silver,  lead,  iron,  and 


B ATiLANCE  —  7>i^a^ io??  of  the  Great  Arteries  in  Continuity.     45 

probably  other  metals,  become  sooner  or  later  completely  absorbed." 
Much  space  is  devoted  to  this  question  of  resistance  to  absorption 
in  the  choice  of  a  ligature,  the  experiments  mainly  being  made 
■with  kangaroo  tendon  and  chromic  catgut,  and  with  ligatures  made 
from  the  peritoneum  of  the  ox.  Silkworm  gut  is  the  most  re- 
sistant, but  is  inconvenient  in  use ;  next  come  peritoneal  ligature 
and  kangaroo  tendon ;  but  chromic  catgut,  which  resists  absorption 
for  a  month  or  more,  the  authors  consider  sufficient  for  all  purposes 
if  the  wound  is  kept  aseptic. 

But  the  two  main  questions  which  the  authors  have  set  them- 
selves to  establish  on  a  definite  basis  are — the  question  of  rupture 
of  the  inner  and  middle  coats,  and  the  mode  of  occlusion  of  the 
artery  by  the  ligature.  We  cannot  help  agreeing  with  the  writers, 
and  accepting  their  case  as  proven,  that  rupture  of  the  coats  is  not 
only  a  needless,  but  a  dangerous  and  unphilosophic  procedure ;  but 
we  cannot  here  even  summarise  the  mass  of  evidence  they  have 
brought  together  in  support  of  their  contention.  And  readers 
must  find  in  the  book  itself  the  description  of  the  "  stay-knot " 
which  the  authors  have  devised  for  ligature  in  continuity.  One 
important  point  to  be  remembered  is  that  when  the  coats  are  not 
injured,  a  larger  surface  of  the  arterial  wall  must  be  put  in  appo- 
sition by  the  ligature,  and  this  is  accomplished  by  the  use  of 
several  strands  of  ligature  applied  in  the  way  recommended.  As 
regards  the  occurrence  of  haemorrhage  after  ligation,  we  may 
quote  the  following  sentence : — "  When  the  coats  are  ruptured 
hemorrhage  will  happen  most  often  with  those  arteries  in  which 
the  outer  coat  is  thinnest,  the  collateral  branches  most  numerous, 
and  the  minimum  of  clot  deposited;  that  in  those  cases  the  full 
force  of  the  blood-current  breaks  upon  and  rends  the  outer  tunic, 
where  it  alone  confines  the  blood  within  its  natural  channel ; 
further,  by  antiseptics  alone  the  great  arteries  of  the  body  cannot 
be  ligated  as  far  as  hemorrhage  is  concerned  with  absolute  safetv, 
but  this  result  may  be  expected  when  with  asepsis  is  combined  the 
employment  of  a  suitable  ligature,  so  applied  as  to  occlude  the 
artery  without  damaging  its  wall."  It  will  be  noticed  that  in  this 
passage,  as  throughout  the  book,  the  authors  adopt  the  barbarism 
"  hemorrhage,"  and  elsewhere  we  have  noticed  "  leucocythemia ;  " 
but  why  do  they  not  in  consistency  write  "  pyemia,"  which  fre- 
quently occurs  in  its  proper  form  ?  Again,  a  little  more  careful 
revision  would  have  avoided  such  solecisms  as  "is"  for  '"are"  on 
two   occasions   (pp.    225,    236);    "equal  for"  as  a  synonym  of 


4fi  Beviews  ovd  Bihliographical  Notices. 

"sufficient;"  "and  wliicli,"  on  several  occasions;  and  siich  a 
sentence  as  the  following — "  The  processes  of  healing  and  inflam- 
mation are  for  all  practical  purposes  identical  in  the  higher 
animals  which  we  have  employed,  with  that  which  is  observed 
following  upon  the  wounds  of  men."  Again,  "  Lancereux," 
"  Kocker,"  "  Volckmann,"  are  evidences  of  want  of  care ;  but 
these  are  minor  blemishes  which  a  future  edition  will  rectify,  and 
we  only  regret  their  occurrence  in  a  work  which  is  in  every  other 
respect  admirable — in  the  completeness  of  its  experimental  work, 
in  the  closeness  and  clearness  of  its  reasoning,  forming  as  it  does 
a  chef  cCoenvre  of  British  surgery. 

It  should  be  added  that  the  book  possesses  an  exhaustive  biblio- 
graphy and  an  admirable  index — indispensable  aids  to  its  study. 


Tuberculosis  and  its  Successful  Treatment.  By  Robert  Bell, 
M.D.,  F.F.P.S.G..  &c. ;  Senior  Physician  to  the  Glasgow  Hospital 
for  Diseases  Peculiar  to  Women,  &c.,  &c.  Glasgow:  D. 
Bryce  &  Son.     1892.     Pp.  60. 

The  treatment  which  Dr.  Bell  advocates  is  that  by  means  of 
calcium  chloride.  He  gives  15-20  grains  three  times  daily,  and 
narrates  several  cases  illustrating  the  successes  he  has  had. 

There  is,  as  well  as  this,  a  good  deal  of  writing  about  Phagocytes, 
Koch,  and  some  other  subjects. 

The  importance  of  the  book  is  not  very  great.  Dr.  Bell's  re- 
marks would  have  been  more  suitably  confined  within  the  limits  of 
an  article  in  one  of  the  medical  journals. 


Differentiation  in  Rheumatic  Diseases  (so-called).  By  HuGH  Lane, 
L.R.C.P.,  M.R.C.S. ;  Surgeon  to  the  Royal  Mineral  Water 
Hospital,  Bath;  Hon.  Medical  Officer  to  the  Royal  United 
Hospital,  Bath.  London  :  J.  and  A.  Chm-chill.  1892.  Second 
Edition.     8vo.     Pp.  121. 

In  the  number  of  this  Journal  for  April  1891,  we  favourably 
reviewed  the  first  edition  of  this  monogi-aph,  which  consisted  of 
a  modest  pamphlet  running  only  to  27  pages.  The  present 
edition  is  of  a  more  ambitious  kind—  running  to  nearly  five 
times  the  length  of  its  predecessor,  dealing  in  considerable  detail 
with   the   treatment   of   the    troublesome    group    of   maladies 


Marie — Souza-I^eite — Esmi/s  on  A  cromef/ali/.  47 

included  under  the  generic  term  "  Rheumatic,"  and  containing 
a  number  of  very  fair  though  necessarily  small  illustrative  plates. 

The  third  chapter  is  on  Gout.  While  somewhat  sketchy,  it 
contains  a  good  deal  of  information  and  valuable  advice  on 
treatment.  We  do  not  like  the  expression  "  anti-goutic  remedies," 
which  occurs  at  page  93.  Mr.  Lane  considers  that  the  "  general 
idea  that  an  acute  attack  of  gout  '  does  good '  and  clears  the 
system  "  "  is  a  mistake  " —  and  we  agree  in  this  opinion. 

Chapter  IV.  gives  advice  as  to  the  mineral  thermal  water 
treatment  as  carried  out  at  Bath.  In  Chapter  V.  this  treatment 
is  shown  to  be  in  no  way  injurious  in  heart  cases. 

We  like  Mr.  Lane's  book  and  recommend  it. 


Essat/s  on  Acromegaly.  By  Dr.  Pierre  Marie  and  Dr.  Souza- 
Leite;  with  Bibliography  and  Appendix  of  Cases  by  other 
Authors.   London :  The  New  Sydenham  Society.  189  L  Pp.182. 

The  thanks  of  the  profession  are  due  to  the  New  Sydenham  Society 
for  their  timely  publication  of  these  essays.  Acromegaly  has  only 
been  recognised  as  a  distinct  entity  for  some  six  or  seven  years,  and 
although  during  that  time  cases  have  been  reported  by  a  good  many 
physicians,  still  the  literature  of  the  disease  has  been  up  to  the 
present,  as  far  as  English-speaking  people  are  concerned,  chiefly 
confined  to  the  various  journals,  most  of  the  text-books  on  medicine 
either  devoting  but  little  space  to  this  malady,  or  else  passing  it 
over  altogether. 

This  want  of  a  complete  and  accurate  account  of  this  curious 
disease  is  now  removed.  The  volume  before  us  contains  nearly  all 
that  is  known  on  the  subject.  It  comprises  the  original  essay  by 
Dr  P.  Marie,  published  in  1885.  He  based  his  description  on  two 
cases  which  he  had  himself  most  carefully  observed,  and  on  five 
otuers  which  had  been  recorded  by  other  physicians  who  did  not 
fully  appreciate  their  nature. 

The  second  and  larger  part  of  the  book  consists  of  a  systematic 
thesis  on  acromegaly  by  Souza-Leite,  a  friend  and  pupil  of  Marie. 
This  essay  is  really  the  classical  description  of  the  disease.  Souza- 
Leite  discusses,  as  fully  as  it  is  possible  to  do,  the  aetiology,  pathology, 
and  symptoms  of  the  malady,  and  devotes  particular  attention  to 
its  diagnosis — a  most  valuable  feature  in  the  case  of  so  unfamiliar  a 
disease.  He  then  gives  accounts  of  36  cases  from  the  notes  of 
several  observers. 


48  Reviews  and  Bibliographical  Notices. 

At  the  end  of  the  volume  the  translator  has  collected  tlie  accounts 
of  10  additional  cases,  some  of  which  were  only  published  in  July, 
1891. 

The  value  of  the  book  is  much  increased  by  a  large  number  of 
woodcuts  and  diagrams  lent  by  Dr.  Marie,  which  show  the  leadiiifj 
features  of  the  disease.  Some  of  these  are  rather  rough,  but  on  the 
whole  they  are  very  instructive. 

The  translation  has  been  done  by  P.  S.  Hutchinson,  M.R.C.S., 
who  has  done  his  part  of  the  work  in  an  admirable  manner.  Indeed, 
for  the  entire  book  we  have  nothing  but  praise. 


The  Water- Cure  in  the  Bedroom  ;  or,  Hydropathy  at  Home.  By  G. 
H.  DouDNEY,  M.B.,  M.R.C.S.  Eng. ;  Late  Resident  Medical 
Officer  to  the  Seamen's  Infirmary,  Rarasgate.  Bristol:  J. 
Wright  &  Co.     Pp.  46. 

This  little  book  consists  of  an  introduction  stating  the  general 
principles  and  rules  of  the  water  treatment,  and  of  a  series  of  articles 
on  the  treatment  of  a  number  of  common  ailments  by  means  of 
hydropathy.  The  ailments  selected  belong  to  that  class  of  chronic 
ailments  that  are  exceedingly  distressing  without  being  dangerous 
to  life,  and  are,  in  consequence,  treated  at  home  by  various  em- 
pirical and  household  measures — such  ailments  as  constipation, 
headaches,  chronic  rheumatism,  indigestion,  &c.  The  author  believes 
that  water  treatment  will  be  found  of  much  use,  and  has  written 
this  book  for  the  general  public  in  the  hope  that  they  may  be  induced 
to  give  it  a  trial,  and  not  to  have  constant  recourse  to  the  "  domestic 
drugging  which  goes  on  so  much  now-a-days."  The  directions 
given  are  admirably  clear;  any  one  can  carry  them  out  without 
fear  of  making  a  mistake.  We  welcome  the  book,  and  believe  that 
it  will  be  found  useful  by  many. 

The  Diseases  of  the  Nervous  System.     By  J.  A.  Ormerod,  M.A., 
M.D.     London:    Churchill.     1892.     Pp.    328. 

This  little  work  is  one  of  Churchill's  Student's  Guide  Series,  but 
is  in  point  of  merit  far  above  the  general  level  of  such  works.  It 
is  indeed  a  most  excellent  guide  to  anyone  wishing  for  an  intro- 
duction to  the  study  of  the  important  and  difficult  class  of  disease 
with  which  it  deals.  The  author  modestly  says  the  work  is  offered 
to  the  student  as  no  substitute  for  the  larger  and  more  elaborate 


GoODFELLOW — 7' he  Jj'wteiir  Value  of  Drear/.  4^ 

treatises  on  the  s;inie  subject,  ''but  only  as  an  introduction  to  lli^ 
■work  and  outline  map  of  territory  to  be  acquired ;  and  should  it 
thus  prove  to  him,  perhaps  by  its  \ery  smallness,  an  encourage- 
ment and  aid,  then  it  Avill  have  served  its  end."  ^Ve  shall  feel 
greatly  surprised  if  it  does  not  become  a  very  popular  guide  trt 
students  of  all  ages,  for  we  know  ven*  few  works  in  which  so  muck 
accurate  information,  clearly  given,  is  to  be  found  compressed  into 
so  few  pages.  It  is  a  work  we  would  most  highly  recommend  t(« 
all  oiu"  readers. 


The  Dietetic  Value  of  Bread.     By  JoHX  Goodfellow.  F.R.M.S- 
London :  Macmillan  &  (^o.     1892.     Pp.  328. 

This  book,  which  is  one  of  Macmillan's  excellent  manuals  for 
students,  is,  we  are  told,  mainly  a  reprint  of  papers  already  pub- 
lished in  the  Bakers  Record.  '•  The  object  of  the  work  is  twf»- 
fold :  First,  to  lay  before  the  general  public  an  account  of  the 
various  kinds  of  bread,  by  which  their  merits  may  be  judged :  and 
secondly,  to  afford  technical  information  to  students  and  others  ou 
the  important  subject  of  the  true  value  of  bread  as  a  food.*' 

In  the  first  chapter  it  is  shown  by  statistical  tables  "  that  to  a 
considerable  number  of  children  bread  is  practically  the  only  food 
supplied,  while  to  the  remainder  it  forms  the  chief  article  of  diet." 
The  importance  of  the  inquiry  is  thus  shown.  The  remaining 
nine  chapters  of  the  first  section  deal  with  the  general  metabolism 
of  the  body,  classification  of  foods  nnd  food-stuffs,  digestion, 
absorption,  and  the  general  principles  of  diet. 

The  second  section,  comprising  nine  chapters,  deals  with  white 
bread.  In  this  part  of  the  book  there  is  much  of  interest,  and 
throughout  evidence  of  wide  research  and  original  Avork.  AVe 
find  notice  of  a  remarkable  unstable  compound  formed  during 
baking,  by  the  combination  of  gluten,  casein,  and  gluten-fibrin 
Avith  some  of  the  disintegrated  starch.  It  has  been  found  that 
Avhen  this  is  acted  hn  by  the  gastric  juice  the  starch  is  set  free 
and  the  glutens  are  much  more  easily  digested  than  if  thev 
had  been  heated  alone.  When  the  compound  is  acted  on  by 
diastase,  the  starch  is  rapidly  couAerted  into  sugar,  the  glutens 
being  set  free. 

Interesting  tables  are  given  to  sIioav  that,  for  the  money  it  costs. 
Avhite  bread  affords  more  nutritive  matter  than  any  other  kind  of 
food.     At  the  same  time  it  is  pointed  out  that  in  bread  the  pro- 

£ 


»m)  AV'tvViCN  <nid  JjibUographicai  Notk-^'S. 

teids  are  deticient  in  proportion  to  tlie  carljohydnites,  and  since 
the  poorer  classes  depend  largely  on  bread  as  their  staple  food,  it 
is  of  great  importance  that  the  proteids  should  be  raised  in  bread, 
so  as  to  make  it  more  nearly  a  perfect  diet.  Furthermore,  it  is 
shown  that  bread  is  deticient  in  lime,  and  therefore,  particularly 
in  the  case  of  children,  must  be  supplemented  by  milk  or  other 
substance  rich  in  lime  and  phosphoric  acid. 

The  results  of  the  expei'imeuts  of  most  physiologists  liaAC  shown 
that  white  bread  is  very  perfectly  digested.  The  author,  in 
t?^|»c'riments  by  artificial  digestion,  found  that  the  waste  in  fine 
white  bread  never  exceeded  3'8  per  cent.  In  experiments  on  him- 
self the  waste  was  4*2  jier  cent. ;  coarser  bi'ead  averaged  4*9  per 
font. :  white  rye  bread,  lO'l)  per  cent. 

Still,  from  a  consideration  of  the  chemical  composition  of  white 
bread,  it  is  concluded  that  ''  it  is  entirely  unsuited  for  infants,  and 
•■\en  when  supplemented  by  milk  the  surplus  of  carbohydrates  and 
the  deficiency  of  fat  cannot  be  entirely  obviated."  These  defects 
are  strikingly  shown  when  bread  is  compared  with  milk,  the 
natural  food  of  infants. 

It  is  highly  satisfactory  to  learn  that  the  author  can  state,  as 
the  result  of  an  exhaustive  series  of  examinations  of  various  foods, 
that  '•  it  is  now  certain  that  the  bread  supplied  to  the  people  of 
England  is  practically  pure."' 

The  third  section,  of  seven  chapters,  is  on  wholemeal  bread. 
"  The  author  is  not  opposed  to  the  use  of  wholemeal  bread,  pro- 
i-ijril  the  meal  U  properly  prepared,''  but  "  he  has  come  to  the  con- 
flusion  that  the  wholemeal  bread  made  from  ordinary  wholemeal 
is  not  always  a  desirable  food."  It  is  not  a  pei-fect  food,  since  it 
yields  too  little  proteid,  and  fat,  and  mineral  matter,  but  a  surplus 
t»f  carbolndrates ;  the  bran  is  not  usually  reduced  to  a  sufficienth- 
iine  state  of  division;  the  digestibility  is  inferior  to  white  bread ; 
and  the  Inilk  is  too  gi-eat  for  the  amount  of  nutriment  yielded. 
Furthermore,  it  is  not  only  indigestible  itself,  but  it  leads,  if  taken 
in  considerable  tjuantity,  to  an  increase  of  waste  in  the  digestion 
of  other  foods.  These  objections  to  ordinary  wholemeal  bread 
apply  in  n)uch  less  degree  to  Jine  wholemeal  bread,  which  is  fairly 
well  digested,  and  unirritating  to  the  digestive  organs.  As  it 
yields  more  alkaline  phos})hates  and  has  a  higher  ])roteid  ratio 
than  white  bread,  it  is  concluded  that  it  may  be  of  special  value 
to  those  who  are  constipated,  who  are  inclined  to  become  corpu- 
lent, to  nursing  and  pregnant  women,  to  children  above  the  age 


Tannei; — liulex  of  IJuea-<e.'<  and  their   7'reatine)i.C.  51 

•of  ten  months,  to  those  "vvlio  have  a  tendency  to  decay  of  tlic 
teeth  (!),  and  to  cliihh'en  incHned  to  rickets. 

The  fourtli  section,  of  ten  chapters,  treats  of  special  breads. 
In  these  chaj^ters  nmcli  vahiable  and  ])ractical  information  will  I)e 
found,  but  ■we  can  notice  only  a  few  points.  Tlie  author  believes 
that  triticumina  bread  is  as  near  a  perfect  food  as  wholemeal 
bread  can  be,  and  tliat  "it  deserves  the  universal  commendation 
which  has  been  accorded  to  it  by  the  medical  and  analytical 
world."  Smith's  patent  germ  bread  is  stated  to  be  "far  superior 
to  fine  white  bread  or  ordinary  wholemeal  bread  as  a  food." 
Bonthron's  gluten  bread  is  "  practically  as  free  from  starch  and 
sugar  as  is  })0ssible,"  and  "  a  valuable  food  for  all  those  who  are 
troubled  with  diabetes,  and  is  by  far  tlie  Ijcst  ])reparation  of  its 
kind  that  has  ever  been  jn'oduced." 

The  two  concluding  short  sections  deal  with  tlie  diseases  and 
abnormal  conditions  of  bread,  and  with  the  medicinal  jiroperties  of 
bread. 

In  conclusion,  we  would  strongly  recommend  this  book  to  our 
readers.  Every  physician  will  find  in  it  much  useful  matter  and 
many  valuable  hints,  which  will  guide  him  in  the  dieting  of  his 
patients — a  matter  which  often  presents  far  greater  difticulty  than 
the  prescription  of  drugs. 


An  Index  of  Diseases  and  their  Treatment.  By  Thomas  ILvwkes 
Tanner,  M.D.,  F.L.8.  Fourth  Edition,  Revised  by  Percy 
BouLTON,  M.D.,  M.R.C.P.,  London ;  Senior  Physician  to  the 
Samaritan  Free  Hospital,  &c.  London:  Henry  Renshaw.  1891. 
Pp.  512. 

This  "Index"  has  been  foimd  useful  by  many  medical  men  in  the 
past,  and  Ave  doubt  not  that  in  the  future  this  edition  will  prove  as 
popular  as  its  predecessors.  It  has  been  revised  and  brought  up  to 
date,  old-fashioned  synonyms  and  obsolete  remedies  having  been 
expunged,  and  new  and  important  mattei*  introduced. 

While  Ave  fully  recognise  that  this  book  has  become  popular 
among  medical  men,  and  that  a  Avork  noAv  in  its  fourtli  edition  is 
in  a  position  to  despise  all  hostile  criticism,  nevertheless  Ave  must 
say  that  Ave  feel  considerable  doubts  as  to  its  use.  It  consists  of  an 
alphabetical  list  of  diseases.  Under  each  heading  Ave  find  a  brief 
list  of  symptoms,  and  a  list  of  drugs  or  of  references  to  formulas 
for  treatment.     There  are  hardly  any  indications  mentioned  as  to 


52  Rcvleics  oml  Bibliograpldcal  Notice-'^. 

wlieii  the  cliifercnt  remedies  are  advisable  or  the  reverse.  AW 
fear  that  the  tendency  engendered  by  snch  an  '-Index"  as  this 
is  to  i>ick  out  a  drug  or  prescription  mentioned  in  the  article  on  the 
disease  in  question,  Avhatever  it  may  be,  and  to  treat  or  attempt  \u 
treat  the  disease  and  not  the  individual  case.  We  think  that  if  an 
index  of  treatment  is  -written,  it  should  be  large  enough  to  discuss 
sit  some  length  the  reasons  for  the  various  lines  of  treatment  men- 
tioned, and  we  believe  that  mere  lists  of  drugs  a\  ith  little  else  arc 
to  be  avoided. 


Die  Behandliing  cler  Taherculose  mif  Tabcrkulocidin.  N'erlUnfige 
Mittheilung  von  Pp.ofessor  D.  E.  Klebs  in  Zurich.  Z-weite 
Aufiage.     Hamburg  and  Leipzg  :  L.  Yoss.     1892.     Pp.  30. 

In  this  pamphlet  Professor  Klebs  details  the  results  which  he  has 
obtained  in  the  treatment  of  tuberculosis  in  animals  and  in  men. 
bv  injections  of  tuberculocidin,  a  purified  tuberculin  from  Avhich 
the  injurious  matters  are  removed,  while  tlie  curative  albumoses 
remain.  The  results  are  said  to  be  of  the  most  encouraging 
description,  and  if  they  are  confirmed  by  other  observers  will,  no 
doubt,  have  an  important  effect  on  the  treatment  of  tuberculai' 
affections. 

Full  details  are  given  of  the  mode  of  using  the  drug,  which  is 
now  an  article  of  commerce,  and  can  be  had  at  six  marks  the 
cubic  centimetre  from  the  Hochster  Farbwerken  in  Huchst  a.  ^I. 


The  Essentials  of  Ilixtologt/,  Descrij'lice  and  Practical^  for  the  U.se 
of  Students.  By  E.  A.  Schafer,  F.R.S.  Third  Edition. 
London  :  Longmans,  Green,  &  Co.     1802.     Pp.  302. 

The  appearance  of  a  new  edition  of  Professor  Schafer's  excellent 
Essentials  of  Histology  will  bo  welcomed  by  all  students  of 
anatomy.  The  present  issue  has  been  extensiveU'  revised,  and 
many  important  alterations  and  additions  have  been  made. 
Among  the  latter  the  most  noteworthy  are  the  results  of  the  new 
jnethods  which  have  been  introduced  by  Golgi  and  his  followers 
for  the  examination  of  the  nerve-centres.  These  new  researches 
are  perhaps  rather  too  briefly  described,  but  are  magnificently 
illustrated  by  drawings  copied  from  the  Avorks  of  Retzius  and 
Ramon  y  Cajal,  as  well  as  by  original  diagrams.  The  author  has 
also   incorporated    in   the   work   the   residts   of   his   own    recent 


Shoemaker — JJate)-io  Med'ica  <iii<l  Tlierapeuilct'.  5l> 

valuable  researches  in  the  structure  of  striped  muscular  tissue. 
The  text  is  illustrated  by  325  drawings,  all  of  great  beauty  ;  and 
the  abundant  illustrations  have  made  it  possible  to  cui'tail  the  text 
within  much  narrower  limits  than  is  usual  in  a  book  of  such  wide 
scope.  The  way  in  which  the  work  is  l^rought  out,  and  its  low 
price,  leave  nothing  to  desire.  On  the  whole,  it  is  a  work  which 
can  scarcely  be  too  highly  ])raised. 


The  New  Sydenliam  Society's  Lexicon  of  Medicine  and  the  Allied 
Sciences.  (Based  on  Maijnes  Lexicon.)  By  Henry  PO'WER, 
M.B.,  and  Leoxard  AV.  Sedgwick,  ^,l.X).  Part  17.  Mas-Mit. 
Loudon:  18*J0. 

At  its  present  rate  of  production  the  younger  suljseriljers  to  tho 
New  Sydenham  Society  will  be  old  men  before  their  ponderous 
Lexicon  is  completed.  This  17th  fasciculus  carries  us  only  into 
letter  ^^I,  and  little  remains  to  say  beyond  chronicling  each  part 
as  it  comes  to  hght.  We  learn  from  this  part  that  Meyhcm  and 
not  Meihom  is  the  correct  orthography  of  the  German  physician 
whose  name  is  perpetuated  in  relation  to  the  follicles  and  cysts 
of  the  eyelids.  The  printing  is  very  carefully  done  ;  we  noticed 
but  one  misprint — viz.,  ]\Iehn,  Camille,  a  French  pharmaceutist, 
which  should  read  Mehi«. 


Materia  Medicn  and  Therapeutics.  Vol.  I.  Bv  .T.  Y.  SHOEMAKER, 
:\r.D.,  and  J.  AuLDE,  M.U.  188ii.  Vol.  II.  By  J.  V.  Shoe- 
maker, M.D.     1891.     Philadelphia  and  London:  F.  A.  Davis. 

We  cannot  but  admire  Dr.  Shoemaker's  ceaseless  energy  and 
capacity  for  work.  He  seems  never  to  tire  writing,  speaking, 
and  travelling,  and  he  is  a  well-knoAvn  figure  at  medical  gather- 
ings outside  his  own  country. 

He  now  presents  us  with  a  new  Avork  upon  ^lateria  -\Iedica 
and  Therapeutics.  The  second  volume  is  entirely  from  his  pen, 
while  in  the  preparation  of  the  first  volume,  which  was  pablisheil 
two  years  previously,  he  had  the  assistance  of  Dr.  Aulde. 

In  compiling  this  work  Dr.  Shoemaker  was  fired  with  the 
hiudable  ambition  to  "cut  loose  from  the  traditional  heresies 
tliat  have  been  handed  down  from  time  immemorial,"  without  at 
tlio  same  time  condemning  as  "obsolete  empirical  methods 
whicli  have  sliown  tlioir  value  in  times  gone  by!''  and  be  hopes 


54  Reciens  cnul  B'ibUo<jraphical  Notices. 

that  liis  Avork  will  receive  from  the  mcclical  profession  a  welcome 
in  keeping-  Avitli  the  care  that  has  been  given  to  its  preparation. 

We  (piite  recognise  that  the  book  has  merits.  It  is  blight ly 
Avritteu  and  Avell  up  to  date.  Yet  we  do  not  think  that  it  at  all 
comes  np  to  the  anthor  s  ideal,  or  exliibits  cUstinctivo  novelty, 
and  it  is  certainly  not  free  from  many  errors  and  inaccuracies 
which  are  open  to  criticism.  The  ih'st  vohnne  is  chiefly  devoted 
to  a  consideration  of  remedial  agents  other  than  (bugs  (oxygen, 
peroxide  of  hydrogen,  and  nitrous  oxide  are  strangely  included), 
and  to  matters  of  general  scope — such  as  pharmaceutical  pro- 
cesses, dosage,  and  the  principles  of  prescribing. 

The  second  volume,  after  a  short  introduction,  deals  exclu- 
sively with  drugs,  and  takes  tliem  up  in  alphabetical  order.. 
Special  attention  is  paid  to  the  therapeutical  applications,  and 
this  is.  in  fact,  one  of  the  best  featm-es  of  the  work. 


Lccons    de     Therapeutique.      Par    G.    ITaye:m.     o"*    tSerie.     Les 
IMedications.     Paris :  G.  Masson.     ISIH.     Pp.450. 

M.  IIayem's  work,  Axiien  completed,  will  occupy  four  volumes. 
The  one  under  notice  is  tlie  third  of  the  series,  and  deals  chiefly 
with  neurotic  remedies  and  with  drugs  acting  upon  the  cardiac 
mechanism. 

The  book  is  pleasantly  written,  and  without  going  profoundly 
into  the  subject,  gives  an  excellent  resume  of  pharmacology  and 
therapeutics.  Several  chapters  are  devoted  to  the  treatment  of 
failing  compensation  of  the  heart,  for  whicli  condition  the  author 
uses  the  uncouth  term  hbu'sitara^vie. 


Lectures  on  Children's  Diseases.  By  Dr.  E.  Hexocii.  Vol.  11. 
Translated  from  the  fourtli  e(htion  (1889)  by  J.  THOMSON. 
M.B.,  F.Ii.C.P.,  Kdin.  London  :  The  New  Sydenham  Society. 
18811. 

We  had  occasion  some  time  since  to  speak  favourably  of  Vol.  I. 
of  this  A\^ork,  and  especially  of  its  essentially  clinical  and  practi- 
cal character.  The  same  characteristics  are  observable  through- 
out this  volume,  and  it  is  needless  to  do  more  than  inchoate  the 
chief  subjects  of  Avhich  it  treats.  Nearly  one-tliird  of  the  book 
is  devoted  to  diseases  of  the  digestive  organs,  Avhich  are  carefully 
described.     The  section  upon  diseases  of  the  urinary  organs  is 


Gant — llie  Lord  of  Ilnman'dii.  .'55 

mainly  occupied  by  au  accoimt  of  nephritis.  Under  the  Leading 
of  Infectious  Diseases  wu  have  scarlet  fever,  measles,  cliickcii 
pox,  chphtheria,  and  typhoid  fever;  and  under  Constitutional 
Diseases  arc  ranked  rheumatism,  anaemia,  pm-pura,  scrofula,  and 
rickets.  The  concluding  chapter  deals  A\-itli  some  diseases  of 
the  skin.  It  makes  no  pretensions  to  completeness,  and  treats 
only  of  those  affections  wliich  are  cither  nmcli  more  common 
in  chilch-en,  ()r  present  A\'ith  them  certain  peculiarities.  The 
entu-e  work  is  an  extremely  valuable  contriltution  to  medicnl 
literatm-e,  aiid  is  deserving-  of  all  praise. 


Tlie  Lord  of  Ilumanitii,  or  the  Testimony  of  Hinuan  Consciousness, 
With  Supplement  on  the  Mystenj  of  Sufferina.  By  Fredei;icK 
James  GanTjF.R.C.S.  Second  Edition.  liondon  :  Longmuus. 
Green,  &  Co.     1891.     Pp.  163. 

Practically  a  reprint  of  the  first  edition,  Commencing  -svitli 
the  three  dominant  passions — Fear,  Cupidity,  and  Love — and  the 
classes  of  mankind  under  the  rule  of  each,  the  author  deals  with 
man  as  an  eA'olutionary  being,  his  conception  of  God,  and  the 
Kevelation  of  Christ.  In  the  midst  of  many  thoughts  and  sur- 
mises there  is  the  one  leading  idea  that  God  is  Love,  and  that  the 
keynote  to  Religion  must  be  found  in  this.  The  book  is  of  deep 
interest,  but  occasionally  the  author  allows  his  subject  to  caiTV 
him  away,  as  on  page  79,  where  the  following  paragraph  occurs. 
We  give  it  in  full,  to  show  the  line  of  thought  to  which  the  latter 
part  owes  its  origin  : — 

"The  Religion  of  the  Atonement,  is  (Se/Z-sacrifice.  The  Law  of  all 
Living  Beings  is  Self-sacrifice,  unconsciously  or  consciously.  The  Jien- 
bird  brooding  over  her  young,  starves  herself  rather  than  forsake  them  ; 
or  she  fights  to  the  death  for  their  preservation,  losing  her  own  life  that 
they  may  live.  And  in  the  '  struggle  for  life,'  the  weaker  arc  sacTiticed 
to  the  '  survival  of  the  fittest.'  All  such  loss  of  Self,  in  a  thousand  forms, 
is  only  the  unconscious  fulfilment  of  the  law  of  self-sacrifice  for  the  good 
of  others." 

The  first  part  is  undeniabh-  true ;  the  parental  instinct  affords 
some  of  the  most  striking — indeed  they  may  be  called  marvellous, 
examples  of  self-sacrifice  ;  but  the  struggle  for  existence — the 
survival  of  the  fittest — is  very  different.  These  afford  the  most 
hideous  picture  of  the  ruthless  trampling  down  of  the  weak  by  the 


56  Reviews  and  Blhliograpliical  Notices. 

strong.     Sacrifice  of  others  to  advance  self  are  often  met  with, 
))ut  self-sacriiice  never. 

It  is  hard  to  imagine  anyone  reading  "  The  Lord  of  Humanity  " 
without  having  his  mind  stirred  up  to  face  some  of  the  problems 
eonnected  with  a  future  life. 


P//e*s  Surgical  Handicraft.  With  235  lUustratious  on  Wood. 
Third  Edition.  Revised  and  Edited  by  T.  H.  R.  Crowle, 
F.R.C.S.,  &Q.,  &Q.  Bristol :  John  Wright  &  Co.  1891.  8vo. 
Pp.  570. 

This  well-known  manual  for  house  surgeons'and  surgical  di'esser.s 
appears  in  its  third  echtion  under  the  careful  editorship  of  Mr. 
Crowle,  Surgical  Registrar  to  St.  ]\Iary's  Hospital.  The  leading 
featm-es  of  the  book  have  undergone  ])ut  little  change,  the 
editor's  endeavour,  as  explained  in  the  Preface,  having  been  "  to 
make  tlie  book  still  more  useful  than  it  has  hitherto  proved 
itself,  and  at  the  same  time  to  depart  in  no  degree  from  what, 
as  far  as  I  can  judge,  would  have  been  the  wishes  of  the  author 
respecting  it."  This  intention  has,  so  far  as  Ave  can  judge  from 
the  perusal  of  various  sections,  been  faithfully  carried  out. 
Though  not  approving  of  all  the  opinions  expressed — e.g.^  the 
treatment  of  fractured  patella  by  ]\Ialgaigne's  hooks — still,  most 
of  these  questions  are  of  such  a  nature  that  the  task  of  decision 
will  not  rest  upon  those  for  whom  the  work  is  specially  prepared. 
We  cordially  Avish  the  book  every"  success  under  its  new  pilot. 
The  paper  and  type  are  good,  but  the  binding  hardly  sufficiently 
strong  for  the  size,  and  probable  treatment,  of  the  volume. 


Abdominal  Surgery.  By  .1.  Greig  Smith,  M.A.,  F.R.S.E. : 
Surgeon  to  the  B]-istol  Royal  Infirmary,  &c.,  &c.  Fourth 
Edition.  Eighty -two  Illustrations.  London  :  .1.  &  A.  Churchill. 
Bristol :  .1.  W.  Arrowsmith.     8vo.     Pp.  80G. 

When  a  book,  Avliich  is  a  treatise  of  eight  hundi-ed  pages  on  a 
special  branch  of  sm-gery,  has  reached  a  fom-th  edition  in  an 
exceedingly  short  space  of  time,  it  is  safe  to  conclude  that  it  has 
met  a  recognised  want,  or  that,  recognising  a  want,  it  has  met  it 
in  a  way  that  has  proved  satisfactory  to  those  professing  surgery, 
[n  any  case,  ])efore  the  coveted  symbols,  ^'- Ed.  Ua."  criticism 
stands  disarmed  and  gives  place  to  congratulation,  which  is  at 


Lane — Griffiths — The  Rlieumatic  Diseases.  bl 

all  ti]iK'S  a.  more  pleasing  duty,  aud  most  pleasing  of  all  wlit;n  the 
nbjeet  of  connnendation  is  in  every  way  wortliy  and  deserving 
of  all  we  ean  say  of  approval  or  flattery.  No  one  who  has  ever 
appealed  to  ^h:  Greig  Smith's  book  has,  we  feel  sure,  appealed 
in  vain  ;  and  in  this  volume,  revised  to  date,  "  several  novel 
methods  of  operating  have  been  introduced."  It  is  a  certain 
inthcation  of  the  wide  appreciation  of  Mr.  Smith's  Avork  to  know 
that  translations  are  being  made  of  this  Edition  into  French, 
Italian,  and  German.  With  only  one  revision  do  we  quarrel — 
-All-.  Smith  has  adopted  Dr.  Harris's  hideous  term,  '•  coeliotomy," 
as  a  synonym  of  "abdominal  section." 


^fateria  Medica,  Pharmacy,  Pharmacology,  and  Therapeutics.  By 
W.  Hale  White,  :M.D.,  F.R.C.P.  London :  J.  &  A.  Churchill. 
1892.     Pp.  614. 

A  C03IPACT  little  volume,  containing  a  marvellous  amount  of 
information  so  arranged  as  to  be  easily  found.  Pharmacy  occupies 
24:  pages ;  Pharmacology,  80  pages  ;  the  bulk  of  the  book  being 
occupied  by  Materia  Medica.  The  non-official  remedies  are  kept 
separate  from  those  in  the  B.  P.  Under  the  heading  of  each  drug, 
in  addition  to  the  usual  information  about  source,  preparations, 
t&c,  there  are  hints  as  to  what  substances  they  may  be  mistaken 
for,  and  a  differential  diagnosis  is  given. 

The  author  seems  to  have  held  the  balance  fairly  ;  unimportant 
substances  being  treated  shortly,  whilst  able  and  well-condensed 
therapeutic  essays  are  given  on  valuable  drugs.  There  are  tables 
of  incompatibles  and  substances  which  precipitate  each  other,  the 
usual  table  of  Latin  phrases,  and  a  capital  table  of  natural  orders, 
like  the  Avell-known  one  in  '"'  Squire's  Companion,"  but  keeping  the 
druo's  in  each  order  tosether. 


The  Rhenmafic  Diseases  (so-called)  with  Original  Suggestions  for 
more  Clearly  Defining  Them.  By  H.  Lane,  L.R.C.P.,  Edin., 
and  C.  T.  Griffiths,  L.R.C.P..  Loud.  London  :  J.  and  A. 
Churchill.     1890. 

'1'he  authors  have  had  the  advantage  of  an  extensive  experience 
among  the  patients  who  flock  to  the  mineral  waters  of  Bath, 
and  the  present  book  is  the  outcome  of  their  personal  clinical 
r<  search.     The  best  feature  of  the  book  consists  in  the  illustra- 


58  JRevu'ics  and  BiOliof/rapJiical  N^otices. 

tioiis,  which  uii-  11  hi  luimhir.  Thry  rt'prosc'nt,  in  au  effective 
way,  the  lesitms  .seen  iu  rhcuniatoid  artliritis,  chronic  rlienma- 
tisni  aud  gout.  Fig-s.  4  and  4'"'  illustrate  the  occiUTeuce  of  pig- 
mentation of  the  skin  in  connection  Avith  rheiuuatoid  arthritis. 
We  cannot  si)eak  so  higlily  of  the  text.  It  is  written  in  a  some- 
what inHated  and  pompous  style,  and  it  is  not  always  easy  to 
decipher  the  authors'  meaning. 

In  the  treatment  of  sciatica  stress  is  laid  upon  the  administra- 
tion of  ammonium  chloride  in  large  doses — 20-30  grs. — tkree 
times  a  day,  and  it  is  asserted  to  be  the  only  drug  which  appears 
to  exert  anything  like  a  specific  action  upon  the  pain. 


Tables-  for  the  Diarpiosis  and  Treatment  of  Siiphilis.  By  J.  K. 
Barton,  M.D.,  Senior  Surgeon  to  the  Adelaide  Hospital,  and 
Past  President,  E.C.S.I.  Third  Edition.  Dublin :  Fannin  &  Co. 
1892.     Pp.  27. 

This  new  edition  of  these  well-known  tables  contains  the  treatment 
of  syphilis.  This  addition  was  made  at  the  request  of  a  number  of 
the  author's  student-friends,  who  had  found  the  former  editions 
very  useful. 

INIr.  Barton's  treatment  consists  of  inunction  of  mercurial  oint- 
ment combined  with  the  use  of  quinine  for  the  earlier  stages  of  the 
disease,  while  in  the  later  stages  he  generally  gives  the  green  iodide. 
It  is  a  pity  that  the  proof-sheets  of  this  little  book  were  not  more 
carefully  corrected,  as  a  large  number  of  typographical  mistakes 
appear  in  it.  We  find  pupules  (for  papules),  esophagus,  sets-pus 
(sero-pus),  mediastinae.  dactylis  for  dactylitis,  ottitis,  and  peri- 
cianium.     AVe  also  read  of  a  condylomata. 

Tlie  chief  feature  in  these  tables  is  the  way  in  Avhich  Mr.  Barton 
has  emphasised  the  more  important  points,  by  means  of  large  print, 
so  that  they  catch  the  eye  at  once — a  circumstance  which  renders 
the  book  easy  for  a  student  to  make  up.  We  expect  that  this 
edition  will  enjoy  even  more  popularity  than  its  predecessors  have 
done. 


CLERY  &  COMPANY. 

High-6l8S8  •  Tailoring, 

rrinr^sD   suits 

In  Irish  and  Scotch,  best  qualities,  from  70/-  to  85/- 

IVIORISriN^G-COAT     SUITS, 

Best  Irish  and  West  of  England  Coatings,  trom  £^  5s.  to  ^5. 

frock:   suits. 

In  Venetian  and    Cloths,   Silk  or  Satin-lined,   from   ^4  15s. 

to  £6  los. 

lVIORI<riNG     COATS    Sc    VESTS 

In  Vicunas  and  Worsteds,  all  weights,  from  65/-  to  80/- 

suPE:Rioir   inr£:sT  of   EMTGr^Ai^D 
trouse:i^i:ngs 

From  18/6  to  26/6. 

Cty^TElRT    COATIMTGS, 

All  Shades,  from  60/-  to  75/- 

DRFSS      SUITS, 

Fine  Twills,  Silk  or  Satin-lined,  from  ^4  15s.  to  £6. 
Dress  Suits,   Best  Black  Cloth.   Silk  or  Satin-lined,  £5   los. 

to  £6  I  OS. 

^est  ^^Workmanship  df  fitting  (Guaranteed. 

C  £  £  g  y""  & ^'^^  p—  ^ 

21  to  27  LOWER   SACKYILLE-ST,, 


CLERY  &  COMPANY. 


^iflTHITE     SKIRTS. 

3  Fold  Irish  Linen  Fronts,  3/6  each,  19/6  per  ^  doz. 

3  do.         Better  quality,  4/6  each,  25/6  per  ^  doz. 

3  do.         Extra  quality.  5/6  each,  31/G  per  ^  doz. 

i>i^e:ss   shii^'ts. 

Extra  Wide  Fronts.   One  Stud,  .Square  Cuffs,  4/6  each,  25/6 

per  i  doz, 
do.  Better  quality,  5/6  each,  31/6  per  j  doz. 

do.  Best  quality,  6/6  each,  37/6  per  h  doz. 

COIL.IL.ARS    Sc    CUFFS. 

3  Fold  Linen  Collars.  Newest  Shapes,  5/6  per  doz. 

4  do.  Best  quality,  7/6  per  doz. 
4             Linen  Cuffs,  do.  1 1/6  per  doz. 

CRICKETINTG     Al^IO     LAlflrN^     TJE:1>^N^IS 
OUTFITS. 

TEN^N'IS    SHOFS    in    Gx*ea,t    Va.i?iety. 


CLERY  &  COMPANY, 

21   to  27  LOWER  SACKYILLE  ST  , 


PART   III. 
SPECIAL    REPORTS. 


REPORT  OX  PUBLIC  HEALTH. 

By  Sir  Chaiiles  A.  Camekox,  Ex-Prcsick-nt,  Di[)luiiuito  {l£otiori< 
Causd)  in  Public  Health,  and  Professor  of  Chemistrv  and 
Hygiene,  R.C.S.I. ;  President  of  the  British  Institute  of  Puhlic 
Health,  and  of  the  Irish  Medical  Association  :  Examiner  hi 
Sanitar-s"  Science,  Roval  Uni^■ersity;  Member  of  Army  Sanitary 
Committee  ;  D.P.H.'  Camb. :  Fellow  of  the  College  of  State 
Medicine ;  Medical  Officer  of  Health  for  Dublin,  &c..  &c. 

ON    SOME    POINTS    IX    THE   ^ETIOLOGY  OF   TYrilOIi:)    FEYEK/' 

The  mortal  statistics,  published  during  the  last  twenty  years 
or  so,  show  that  with  rare  exceptions  the  zymotic  death-roll 
is  steadily  declining  in  all  parts  of  these  countries.  lu  Dublin, 
for  example,  the  deaths  from  the  i)rincipal  zymotic  diseases- 
were,  in  the  period  1876-80,  in  the  ratio  of  5'29  per  1.000- 
persons  living.  In  the  next  quinquennial  period  the  rate  declinetl 
to  3'OG  :  in  the  five  years  ended  in  1890  the  rate  further  declined 
to  2'86 ;  and  in  1891  it  Avas  only  1*7 — which  was  lower  than  the 
mean  rate  in  the  twenty-eight  large  English  towns.  The  mean 
zymotic  death-rate  in  twenty  largest  English  towns  in  the  period 
1882-1886  was  3-14  •  but  in  the  five  years  1887-1891  it  was 
reduced  to  2*78  per  1.000  persons  living. 

AVhilst  the  zymotic  death-rate  has  declined  in  a  very  marked 
manner  in  Dublin,  and  in  British  and  Irish  towns  generally,  there 
has  not  been  a  corresponding  reduction  in  the  mortality  ascribed 
to  typhoid  fever.  On  the  contrary,  in  some  towns  it  has  remained 
stationary,  or  even  shown  a  tendency  to  increase.  In  Birmingham, 
for  example,  it  has  not  declined,  and  in  Belfast  and  Dublin  it 
has  increased.  Through  the  kindness  of  the  medical  officers  of 
health  of  forty-nine  lax'ge  towns  or  districts,  I  have  been  able  to 
ascertain  the  mortality  caused  by  typhoid  fever  in  those  places, 
and  I  have  arranged  them  in  the  following  table  : — 

"  Tlie  Cavendish  Lecture,  ck-livered  before  the  ^Vest  London  Medico-C'hirurgical 
Society,  2nd  June,  1892,  by  Sir  C.  A.  Cameron, 


Deaths  from   Typhoid  Fever  per  10,000  Persons  lioiiir/  in  the 
following  Places. 


Place 

1 
1 

Year 

Average 
tor  5 
years 

USS7 

188S 

ISSO 

I8!I0 

1S91 

1 
Woolwich 

0-73 

0-49 

0-98 

0-73 

0-73 

-730 

Kensington 

0-60 

1-20 

1-10 

0-90 

1-40 

1-OiO 

Paddington 

0-99 

1-30 

1-40 

0-80 

1-40 

1-180 

Islington 

1-03 

1-61 

1-62 

0-92 

0-87 

1-210 

Croydon 

0-85 

1-35 

0-91 

1-09 

106 

1-250 

Bristol 

1-00 

1-20 

1-70 

1^40 

1-00 

1-260 

Brighton 

1-60 

1-30 

1-50 

I'lO 

1-10 

1-320 

Camberwell 

1-74 

1-32 

1-15 

1-106 

* 

1-329 

Whitechapel     - 

0-80 

1-70 

1-20 

2-10 

•90 

1-340 

Cork 

2-25 

1-25 

■50 

■87 

1-87 

1-848 

Bradford 

1-43 

0-82 

2-04 

1-29 

1-24 

1-364 

Chelsea 

2-89 

■63 

1-37 

1-15 

•82 

1-372 

Edinburgh 

1-46 

1-02 

1-19 

1-62 

1-60 

1-378 

Wolverhampton 

1-75 

1-36 

1-10 

1-09 

1-81 

1-422 

Hackney 

2-00 

115 

1-25 

1-30 

1-G3 

1-466 

Pancras 

]-19 

2-43 

1-24 

l-3(> 

1-15 

1-474 

Newcastle 

2-70 

1-40 

1^00 

1-30 

1-00 

1-480 

Huddersfield    - 

1-00 

1-30 

1-10 

2-50 

1-60 

1-500 

Dundee 

2-10 

1-30 

1^02 

1-40 

1-80 

1-524 

Birmingham     - 

1-90 

1-50 

1-00 

1-40 

1-80 

1-520 

South  Shields 

1-15 

1-39 

1-08 

2-35 

1-89 

1-572 

Shoreditch 

2 '02 

1-62 

1-37 

1-27 

1-63 

1-582 

Southwark 

2  00 

Nil 

Xil 

2-00 

4-00 

1-600 

Oldtown,  Mile  End      - 

1-50 

1-40 

1-25 

1-96 

1-96 

1-614 

Holborn 

1-73 

1-17 

1-17 

2-05 

2^15 

1-645 

Hull     - 

1'40 

1-60 

2^10 

1-60 

1-80 

1-700 

Southampton    -       , 

1-23 

1-07 

0-77 

0-92 

1-37 

1-720 

Oldham 

2-02 

1-90 

1-5G 

115 

2-04 

1-734 

Derby  - 

2-10 

2-90 

1-10 

1-80 

1-10 

1-800 

Glasgow 

1-90 

1-10 

2-00 

1-90 

2-20 

1-820 

Leicester 

1-89 

2-24 

1-54 

1-68 

2-03 

1-876 

Gateshead 

2-00 

1-80 

1-00 

5-00 

1-30 

1-884 

Halifax 

1-51 

1-12 

2-71 

1-58 

2 -65 

1-914 

Norwich 

1-83 

1-5G 

1-72 

3-32 

1-40 

1-970 

Londonderry    - 

2-33 

0-66 

2  00 

4-30 

1-00 

2-058 

Swansea 

2-90 

1-90 

2-00 

2^00 

2-40 

2-240 

Cardiff 

1-62 

3-31 

2^58 

1-96 

1-84 

2-262 

Liverpool 

2-40 

2-40 

3-20 

1-90 

1-80 

2-340 

West  Bromwich 

1-44 

1-26 

3^06 

2-52 

3-96 

2-448 

Bolton 

2-75 

2-73 

2-70 

1-89 

2-58 

2-530 

Portsmouth 

3-61 

1-80 

2-08 

319 

2^06 

2-548 

Birkenhead 

2 '25 

326 

3-53 

3-00 

-t 

3-010 

Plymouth 

3-20 

3-00 

3-80 

3-90 

1-30 

3-040 

York    - 

3-71 

1-85 

3-28 

3-14 

3-42 

3080 

Merthyr  Tydvil 

4-50 

reo 

4-30 

2  60 

2-20 

3-100 

Preston 

5-50 

2-60 

o-OO 

2-30 

2-90 

3  660 

Middleborough 

2-30 

1-70 

2-70 

8-20 

7-60 

4  500 

Salford 

4-30 

4-70 

r>-80 

4-20 

3-80 

4560 

Dublin 

3-80 

4-70 

6-00 

5-30 

5-40 

5-040 

St.  Helen's 

5-10 

310 

11^20 

3-40 

3-30 

5  ■2-20 

Belfast  - 

Mean  rate  in  50  towns 

3-40 

3-10 

7-40 

7-00 

5-90 

5-360 

2-18 

1-80 

2-28 

2-296 

207 

1-124 

Kot  given. 


t  Xot  ascertained. 


Report  0)1  Public   Health.  Gl 

The  table  shows  that  in  Dubhu  typlioid  fever  causes  a  greater 
waste  of  life  than  in  any  English  town  except  St.  Hclen'^, 
and  in  Ireland  it  is  exceeded  only  hx  Belfast.  Both  Dublin  and 
Belfast  are  rather  loAv-lying  cities,  situated  upon  the  estuaries  of 
rivers,  and  at  present  are  badly  drained. 

Professor  Notter.  of  Netley,  has  pointed  out  the  marked  increase 
of  typlioid  fever  in  the  European  army  in  India,  which  is  all  the 
more  remarkable  as  the  general  and  zymotic  death-rates  in  that 
army  have  decreased.  During  the  ten  years  ended  in  1879  the 
deaths  amongst  the  troops  ascribed  to  typhoid  fever  -were  in  the 
ratio  of  2-03  per  1,000:  in  the  period  1880-85  they  were  2*98 
per  1,000;  in  1887,  3-76;  and  in  1888,  3-75.  Compared  with 
these  rates  the  mortality  caused  by  this  disease  in  British  cities, 
even  in  Dublin,  seems  trivial.  In  some  foreign  cities  the  rates, 
too,  are  very  high.  For  example,  it  is  stated  that  the  deaths  front 
typhoid  fever  in  Chicago,  United  States  of  America,  Avere  in  1890 
in  the  ratio  of  9  per  10,000  persons  living;  and  in  1891,  22  per 
10,000.  In  many  Italian  cities  typhoid  fever  is  more  fatal  than 
in  Dublin. 

Typhus  fever  caused  formerly  frightful  ravages  in  Dublin,  and 
even  within  a  comparatively  recent  period  it  was  rather  rife.  If 
we  compare  the  mortality  produced  by  this  disease  with  that 
attributed  to  typhoid  feAcr  during  recent  years,  it  will  be  seen  that 
the  former  is  rapidly  dying  out,  whilst  the  latter  is  increasing. 

DEATHS    IX    DUBLIN    :\IETEOPOLIT.yS'   REGISTRATION    DISTRICT 
CAUSED  BY  TYPHUS  AND  TYPHOID  FEVERS. 

Tear 
1881 

1882 
1883 
1884 
1885 
188G 
1887 
1888 
1889 
1890 
1891 

The  lessened  death-rate  in  our  towns,  and  more  especially  the 
decrease  in  the  mortality  caused  by  the  infective  diseases,  taken 


Typhus 

Typhoid 

194 

123 

84 

135 

141 

132 

83 

134 

54 

144 

39 

129 

24 

135 

31 

168 

18 

228 

25 

185 

6 

191 

<j-2  Uepovf  on  Fnhl'ii-   IfeaJth. 

;)8  a  group,  are  unquestionably  due  to  the  improved  hygienic  con- 
<litions  under  wliich  the  urban  populations  are  now  placed.  The 
ohief  modern  sanitary  reforms  are  as  follows: — The  introduction 
of  ain))le  supplies  of  water,  taken  from  sources  little  likely  to  be 
])olluted;  the  main  drainage  of  towns;  improvements  in  the  con- 
struction and  Avorking  of  street  sewers;  the  better  methods  of 
getting  rid  of  the  effete  matters  produced  in  dwellings;  the  abate- 
ment of  the  more  serious  trade  nuisances ;  the  prevention  of  over- 
crowding in  tenement  houses;  the  demolition  of  houses  unfit  for 
human  occupation ;  the  erection  of  improved  dwellings  for  the 
working  classes;  the  S3'stematic  purification  of  infected  dwellings, 
clothing,  and  bedding;  the  better  provision  for  treating  and  isolating 
fever  cases;  the  various  general  Public  Health  Acts;  the  statutes 
relating  to  artisans'  dwellings,  to  pollution  of  water-courses,  to 
vaccination,  to  the  diseases  of  the  animals  used  as  food  by  man, 
and  the  providing  of  parks,  recreation-grounds,  and  open  spaces  in 
towns.  The  numerous  local  Improvement  Acts,  also,  usually  con- 
tain valuable  clauses  relating  to  sanitary  matters. 

These  Acts  of  Parliament,  aided  by  the  efforts  of  sanitary 
associations,  of  individual  sanitarians,  of  hygienic  literature,  and 
a  more  general  laiowledge  and  appreciation  of  the  natural  laws 
of  health,  ai'e  lessening  decade  by  decade  the  difference  bett\-een 
urban  and  rural  death-rates. 

The  persistence  of  typhoid  fever  in  so  many  towns  in  which 
other  zymotics,  notably  small-pox  and  typhus  fever,  have  died  out  or 
are  dying  out,  indicates  that  the  sanitary  measures  hitherto  adopted 
have  had  less  eflfect  upon  this  fever  than  upon  other  infective 
jnaladies.  The  more  intimate  nature  of  this  disease  and  the  modes 
by  which  it  is  propagated,  are  subjects  which  possess  great  interest. 

Typhoid  fever  is  probably  co-extensive  with  man ;  but  it  is  more 
prevalent  in  some  countries  than  in  others,  and  in  many  parts  of  the 
world,  including  the  British  Islands,  it  is  endemic.  There  seems 
to  be  little  doubt  as  to  the  disease  being  caused  by  a  micro-organism. 
The  Bacillus  typhoms  has  been  described  by  Eberth,  Gaffky, 
Fraenkel  and  Simmonds,  Klebs  and  Eppinger,  Koch,  Myer  and 
Friedliinder,  Hutimeyer  and  Neumann,  Coates,  Crookes  and  others. 

This  organism  has  been  found  in  the  blood,  spleen,  liver, 
kidneys,  and  other  organs,  and  in  great  numbers  in  the  mesenteric 
yjlands.  It  has  been  "  cultivated  "  in  various  nutrient  materials,  and 
it  is  stated  that  typhoid  fever  has  been  induced  by  inoculation  with 
this  bacillus.     Mond  found  them  in  a  well    at  Civray,   France, 


Report  on  Public  Health.  (13 

during  an  epidemic  of  typhoid  fever  in  1880.  Other  observers 
have  detected  them  in  water;  Neumann*^  found  them  in  urine.  The 
bacilli  form  rods,  some  very  short,  otliers  2  /m  broad,  and  forminoj 
filaments  up  to  50  fi  in  length.  They  are  occasionally  constricted 
in  the  middle  and  exhibit  spore  formation. 

The  question — Can  an  attack  of  typhoid  fever  occur  without  an 
antecedent  one,  has  often  been  discussed,  and  has  been  answered 
affirmatively  by  one  of  the  greatest  authorities  on  the  subject  of 
fever,  the  late  Dr.  Murchison.  The  spontaneous  origin  of  the 
materies  morhi  of  the  disease  by  the  decomposition  of  fa?cal  matters, 
is  a  theory  which  recent  bacteriological  research  has,  I  think, 
completely  exploded.  In  the  most  recent  work  on  the  eruptive  antl 
continued  fevers — that  of  Dr.  John  William  Moore — the  author 
admits  that  the  pythogenic  theory  of  typhoid  fever  can  no  longer  be 
maintained,  although  he  himself  formerly  was  disposed  to  believe  in  It. 

There  being  a  consensus  of  medical  opinion  in  favour  of  the 
microbian  origin  of  typhoid  fever,  the  biology  of  the  microbe  comes 
to  be  a  subject  of  great  interest. 

There  are  pathogenic  microbes  which  apparently  soon  perish 
when  detached  from  the  animals  in  which  they  have  been  developed, 
whilst  others  are  more  persistent,  and  the  spores  of  many  kinds  long 
retain,  like  vegetable  seeds,  their  vitality  and  power  to  develop  under 
favourable  conditions.  When  supplied  with  nutrient  material,  such 
as  gelatine,  potato,  &c.,  the  pathogenic  microbes  seem  to  live  and 
multiply,  from  which  we  may  infer  that  they  may  when  detached 
from  animals  become  deposited  by  accident  in  dead  organic  matter 
capable  of  affording  nourishment  to  them.  It  may,  however,  be 
reasonably  assumed  thi.t  the  great  majority  of  the  pathogenic 
micro-organisms  would  soon  perish  if  the  animals  with  which  they 
are  associated  ceased  to  exist.  It  is,  moreover,  quite  certain  that 
the  microbes  which  produce  some  diseases  would  continue.  For 
example — the  Bacillus  malarias  and  ama-boid  bodies,  and  no  doubt 
the  bacilli  and  other  micro-organisms  producing  all  kinds  of  inter- 
mittent fevers,  have  an  independent  existence.  They  are  found  in 
the  soils  of  many  marshy  districts,  or  rich  alluvium,  and  in  the 
polders  and  banks  of  rivers,  especially  in  tropical  and  sub-tropical 
climates.  They  existed  abundantly  in  these  islands  in  former  times, 
and  have  been  got  rid  of  by  the  drainage  and  cultivation  of  the  soil. 
These  organisms  are  clearly  of  the  earth ;  but  they  produce  specific 
diseases  in  man. 

®  Berliner  klinische  Wochenschrift.     1390. 


64  Report  on  Public  Health. 

The  great  variety  of  forms  which  malarial  fever  or  ague  assumes 
seems  to  indicate  a  plurality  of  poisons:  which,  indeed,  may  be  the 
case,  but  to  a  more  limited  extent,  with  typhoid  fever.  Malarial 
organisms  have  been  described  recently  by  Laverna,  Terni,  and 
Girardlni,  Marchlafi^va  and  Cell!.  Golgi  says  that  the  various 
forms  of  malaria  are  the  results  of  the  action  of  different  micro- 
organisms. The  poison  of  malaria  is  conveyed  to  man  chiefl}'  by 
the  medium  of  the  air,  and  the  characteristic  organisms  of  the 
disease  may  be  often,  it  is  said,  found  in  the  sweat  on  the  bodies  of 
the  people  living  in  malarial  districts.  Water,  however,  it  is  well 
known,  can  hold  in  suspension  malarial  poison  and  retain  it  for 
considerable  periods  of  time.  In  the  United  States  it  Is  a  general 
belief  that  milk  is  sometimes  the  vehicle  of  this  disease,  and  that  it 
is  spread  also  by  the  muscadine  grape  which  grows  in  marshes. 
The  rough  and  often  glairy  surface  of  this  grape  catches  and  retains 
the  malarial  poison.  In  India,  France,  and  other  countries  in  which 
malarial  fevers  occur,  they  have  been  in  part  attributed  by  competent 
observers  to  the  use  of  water  containing  the  poison  of  the  disease. 
Without  admitting  or  denying  the  theory  that  tliere  is  a  kind 
of  hvbrld  fever — typho-malarial — intermediate  between  typhoid 
fever  and  ague,  I  am  disposed  to  believe  that  in  relation  to  their 
propagation  there  are  several  points  of  resemblance  between  typhoid 
fever  and  the  intermittent  fevers.  The  intimate  connection  between 
them  has  been  pointed  out  by  Dr.  Harley  in  the  Lumleian  Lectures 
for  1880.  Johnston,"  treating  of  Continued  Fevers  of  the  South 
(of  the  United  States)  says  that  it  is  probably  changing  its 
character  in  that  region,  is  assuming  a  less  defined  type,  and  a 
milder  form.  He  believes  that  many  cases  of  so-called  malaria 
are  really  typhoid  fever,  and  he  concludes  by  acknowledging  the 
existence  of  a  typho-malarial  fever. 

Kinvoun'^  found  the  Plasmodium  malaria'  in  the  blood  of  fever 
patients,  and  the  bacillus  of  Eberth  in  their  urine.  He  suggests 
for  such  fever  the  term  entero-nialarial. 

It  is  established  that  malaria  is  not  directly  communicable  from 
the  healthy  to  the  sound,  but  the  same  is  almost  true  in  reference 
to  typhoid  fcAcr.  The  malarial  poison  is  generally  believed  not  to 
be  reproduced  in  the  human  body,  in  which  respect  it  dififers  from 
that  of  typhoid  fever;  but  Cuboni,  Marchlafava,  and  Gerhardt 
have  proved  that  malaria  is  inoculable  from  man  to  man.     Typhoid 

■  Philadelphia  Medical  Bulletin.     1890. 

''  New  Orleans  Medical  and  Surgical  Journal.     May,  1890. 


Ri'povt  on   J-'nblic   llcalfh.  ^5 

fever  is,  like  nuilaria,  propagated  through  the  media  of  air,  water, 
and  food;  the  })oi<oii  of  both  diseases  exist,  in  tlie  soil.  That  of 
malaria  unquestionably  ascends  from  the  earth,  and  so  also,  pro- 
bably, do  the  microbes  of  typhoid  fever.  The  natural  habitat  of 
the  malarial  organisms  is  the  earth:  is  this  also  the  case  with 
the  Bacillus  hiphosus  f  The  biology  of  the  organism  is  as  yet  so 
little  known  that  it  is  impossible  to  state  positively  whether  or  not 
it  is  capaljle  of  multiplying  indefinitely  in  the  soil.  Dr.  Justin 
Karlinski  states  that  it  does  not  exist  longer  than  three  months 
in  the  earth ;  and  that  when  exposed  on  the  surface  of  the  ground 
to  sunlight  and  moisture,  it  quickly  perishes.^  But  although  tli-3 
organism  dies  its  spores  may  long  survive,  and  under  favourable 
<-onditions  develop  into  the  mature  organism.  I  have  carefully 
studied  Karlinski's  memoir,  but  he  has  not  convinced  me  that  the 
organisms  which  produce  typhoid  fever  completely  and  quickly 
perish  in  the  soil.  Dr.  Prudden,  of  New  York,  found  that  typlioid 
bacilli  after  confinement  for  103  days  in  ice  retained  their  vitality. 
Cassedebat  states  that  they  can  live  at  least  44  days  in  distilled 
water.  According  to  Grancher  and  Deschamps  they  survive  for 
months  in  soils,  although  surrounded  by  numerous  other  orfjanisms. 

As  an  exam]  lie  of  a  ^•iew  diametrically  opposite  to  that  of 
Karlinski's,  I  may  quote  an  opinion  expressed  by  Dr.  Farquharson 
in  a  pa}ier  circulated  l)y  the  Iowa  Board  of  Health  in  1883. 
Dr.  Farquhai-son,  after  pointing  out  the  resemblance  between 
typhoid  and  malarial  fevers,  says — "  Our  farmers  would  not  if  they 
<'Ould  do  away  with  the  exuberant  richness  of  the  virgin  soil,  nor 
'liminish  the  almost  tropical  temperature  of  our  summers,  yet  these 
are  the  prime  factors  iu  the  production  of  typhoid  fever.'' 

I  am  disposed  to  look  very  favourabl}'  upon  Dr.  Woodhead's 
theory,  that  all  bacilli  are  primarily  saprophytes — that  is,  have  au 
independent  existence  apart  from  animals  ;  and  that  they  become, 
under  altered  conditions,  pathogenic,  and  prey  upon  living  tissues.'-' 
The  sapro])hytes  are,  with  perhaps  the  exception  of  the  micro- 
organisms connected  Avitli  malarial  diseases,  innocuous ;  but  under 
certain  conditions,  at  present  not  well  miderstoocl,  i\\Q\  may  acquire 
\irulcnce. 

Those  eminent  bacteriologists,  A.  Rodet  and  G.  Roux,  have 
stated  very  positively  that  the  typhoid  bacillus  of  Eberth  is  merely 

"  Archiv  f.  Hygiene.     Bd.  XIII.     Heft  3. 

''Bacterica  and  their  Products.  By  German  Sims  Woodhead,  ^I.D.  London: 
Walter  Scott.     1S91. 


(}Q  Report  on  Pnhlic  Health. 

an  altered  and  virnlent  form  of  the  Bacillus  coli  communis  describect 
by  Eschericli.  This  assertion  is  a  very  remarkable  one.  Pasteur 
and  others  have  shown  that  the  -•attenuation"  or  degeneration 
of  certain  pathogenic  microbes  greatly  reduces  their  virulence, 
and  may  even  render  them  completely  innocuous. 

According  to  Rodet  and  Roux*  the  bacillus  coli  communis, 
witliout  losing  its  general  botanical  characters,  acquires  a  toxic 
nature  within  the  human  organism,  and  becomes,  in  fact,  Ebcrth's 
typhoid  bacillus.  The  researches  of  Rodet  and  Roux  seem  further 
to  show  that  the  Bacillus  coli  communis,  which  may  exist  in  the 
human  organism  without  doing  injury  to  the  latter,  can  become 
highly  ^"irulent  and  infective  when  introduced  into  water.  Hence 
they  conclude  that  not  only  typhoid  dejections,  but  simple  fajcal 
pollution  of  water  may  produce  typhoid  fever  in  those  who  di-ink 
it.  This  view  would  seem  to  favour  Murchison's  pythogenic 
theory;  but  they  reall}^  differ  completely.  In  the  latter  it  is 
assumed  that  the  toxic  principle  of  typhoid  fever  may  originate 
in  decomposing  fa;cal  matter ;  but  according  to  Rodet  and  Roux's 
theory  a  harmlesss  saprophytic  organism  acquires  by  mere  contact 
with  water  new  and  infective  properties. 

The  recent  investigations  of  Vallet^  seem  to  confirm  Rodet  s  and 
Roux's  opinions.  He  shoAvs  that  the  Bacillus  coli  commimis  differs 
but  slightly  from  Eberth's  bacillus,  and  that  both  are  infective. 
The  former  flourishes  in  cesspools — why  not,  therefore,  in  filth- 
laden  soils  ? 

It  seems  not  improbable  then  that  an  organism  Avhich  can  exist 
for  at  least  some  weeks  in  earth  and  water  is  the  materies  morhl 
of  typhoid  fever.  It  may  be  harmless  until  it  has  undergone 
certain  transformations  in  the  system,  or  it  may  be  immediately 
infective.  Such  an  organism  is  clearly  much  nearer  akin  to  the 
microbes  of  malarial  disease  than  to  those  of  such  affections  as 
gonorrhoea,  typhus  fever,  or  measles.  The  condition  of  soils  or 
Avater  has  little  relevancy  to  these  and  most  other  of  the  infective 
diseases ;  but  it  has  a  great  deal  to  do  with  remittent,  intermittent 
and  typhoid  fevers — perhajis,  also,  with  dysentery  and  diphtheria, 
which  are  probably  malarial  diseases. 

Even  if  we  do  not  admit  that  the  microbes  of  typhoid  fever  can 
multiply  in  soils,  it  must  be  conceded  that  they  can  exist  therein 

"  Comptes  Eendus  de  la  Societie  de  Biologic.     Tome  II.     No^7.     1890. 
''  Le    Bacillus    Coli  Communis   dans   ses   Eapports   avec  le   Bacille   d'Eberth   et 
TEtiologie  de  la  Fifevre  Typhoide.     Paris.     1892. 


Report  on  Public  Health.  07 

for  at  least  some  time.  Some  soils  are  better  adapted  than  others 
to  the  continued  existence  of  these  and  other  micro-organissms. 
Free  movement  of  air  and  Avater  in  soils  is  favourable  to  the 
development  and  prolongation  of  such  forms  of  life  as  exist  in  the 
earth.  In  stiff  clays  there  are  few  organisms.  Air  below  ground 
differs  greatly  as  to  the  percentages  of  its  constituents  from  the 
overground  atmosphere.  It  is  extremely  rich  in  carbonic  acid, 
derived  from  the  decomposition  of  organic  matter.  Owing  to  the 
kinetic  law  of  gases,  an  incessant  interchange  is  going  on  between 
the  overground  and  subterranean  atmospheres;  air  is  penetratin*' 
downwards  into  the  soil,  and  the  gases  contained  in  the  latter  are 
diffusing  into  the  space  overground.  There  are  interchanges  between 
the  two  atmospheres  brought  about  by  other  causes — as,  for  example, 
differences  between  the  temperature  of  the  ground  and  the  general 
atmosphere;  the  action  of  winds;  the  warming  of  houses,  which 
causes  an  insuction  of  air  from  the  ground.  Tiie  ascent  of  ground 
water  and  the  descent  of  rain  cause  expulsion  of  underfjround  air 
and  the  descent  of  the  ground  water  draws  the  outer  air  into  the 
soil. 

The  connection  between  the  sinking  of  ground  water  and  the 
occurrence  of  typhoid  fever  has  been  investigated  with  great  care 
by  Professors  Pettenkofcr  and  Buhl,  of  Munich.  They  found  that 
the  cases  of  typhoid  fever  increased  whilst  the  ground  water  Avas 
sinking,  and  that  they  were  most  numerous  when  the  water  having 
been  unusually  high  sunk  rapidly  to  the  lowest  level.  This  theory 
has  been  supported  by  many  eminent  epidemiologists,  and  opposed 
by  others.  It  holds  good  as  applied  to  several  German  towns;  but 
it  is  stated  that  in  others  no  relation  between  the  sinking-  of 
ground-water  and  increase  of  typhoid  fever  has  been  noticed.  In 
England  Pettenkoter's  theory  has  not  received  much  support.  Ah 
elaborate  official  Report  upon  the  ])revalence  of  the  disease  in  Coloo-ne 
was  issued  in  1889,  Avhich  attributes  it  not  to  fluctuations  of  the 
underground  water,  but  rather  to  the  temperature  and  coniposiridu 
of  the  subterranean  atmosphere,  the  proportion  of  bacterial  life  iu 
it,  and  the  opportunities  afforded  the  micro-organisms  to  invade  the 
atmosphere. 

Localised  outbreaks  of  typhoid  fever  can  frequently  be  directlv 
traced  to  the  use  of  a  particular  supply  of  polluted  water  or  milk 
but  the  widespread  epidemics  of  this  disease,  and  even  its  persistent 
occurrence  in  so  many  towns,  must  be  due  to  some  other  cause  or 
causes.    For  example,  In  Dublin  it  Avas  epidemic  in  1891-92.  and  in 


•58  Rqioi't  on   Pnhlu-  Health. 

1889  it  appeared  in  all  ])arts  of  the  city  and  adjacent  districts. 
The  city  and  all  its  subnrbs.  with  one  exception,  are  supplied  with 
water  procured  from  a  gathering  ground  26  miles  distant,  in  a 
mountainous  region  of  the  County  of  Wicklow.  There  are  Aery  few 
persons  li\ing  on  the  drainage-shed  wdiich  furnishes  the  Dublin 
pipe-water,  and  of  those  few  nearly  all  reside  in  a  small  a  illage 
dose  to  the  reservoir  in  Avliich  the  Avater  Is  impounded.  Last  year 
it  Avas  asserted  that  a  portion  of  the  drainage  of  the  A-illage  passed 
into  the  reser\'oir,  but  the  statement  Avas  completely  refnted.  I 
l)elie\e  there  are  fcAA*  cities  in  the  AA'orld  supjdied  Avitli  sucli  good 
water  as  Dublin  fortunately  possesses.  I  make  this  statement  from 
tlie  result  of  many  careful  examinations  of  the  reserA'oir  and  its 
surroundings,  and  of  hundred  of  chemical  and  biological  examina- 
tions of  the  AA^ater.  There  are  A"erv  feA\'  wells  now  in  Dul)lin,  and 
only  an  almost  infinitesimal  proportion  of  the  Avater  drank  by  the 
inhabitants  is  obtained  from  those  sources.  I  dwell  u])on  the  fact 
that  Dublin  has  a  Aery  pure  AA-ater  supply,  because,  in  \ieAA'  of  the 
undoubted  fact  that  typhoid  fcAer  is  propagated  by  the  medium 
of  infected  AA-ater,  it  is  noteworthy  that  Dublin  has  almost  the 
highest  typhoid  fcA-er  death-rate  in  the  United  Kingdom. 

The  one  suburb  of  Dublin  (Ratlimines  ToAvnship,  ])0])ulation 
27,410),  Avliich  has  an  independent  supply  of  Avater.  derives  it 
also  from  a  pure  source,  the  gathering  grounds  being  districts 
In  the  Dublin  Mountains  composed  of  granite  and  silurian  rocks. 
In  Rathmines  ty})hoid  fe\er  prewails  much  to  tlie  same  extent  as 
in  the  other  toAvnsliips,  Avhich  are  placed  under  similar  conditions 
ns  regards  site  and  drainage. 

The  street  scAAcrs  in  Dublin  are  of  excellent  construction,  and 
many  of  the  more  important  ones  liaAc  been  recently  reconstructed. 
Unfortunately  at  present  they  deliver  their  contents  into  a  tidal 
I'iver  (the  Liffey)  Avhlch  bisects  the  city.  The  mouths  of  the 
scAvers  are  pi'OAided  AAith  Aalvular  gates,  Avhich  close  and  open  as 
\\\e  tide  in  the  river  rises  and  falls.  Some  of  the  seAA'ers  are  sealed 
r;p  for  the  greater  part  of  the  twenty-four  hours,  and  consequently 
their  contents  accumulate,  and  have  to  be  in  part  removed  by  the 
usual  method  of  pumping  them  up  to  a  higher  level,  from  Avhence 
they  are  run  into  the  riA'er.  The  scAvers  are  jiroAided  Avith  the 
usual  ventilators,  Avhicli  alloAv  a  free  communication  JjetAveen  them 
and  the  street  air.  It  AA'ill  be  seen  then  that  Dublin  is  a  Ioav- 
lying  city.  The  floors  of  the  basement  stories  of  many  houses  are 
!iot  above  the  level  of  the  highest  tides,  and  some  are  actually 


Report  on  Public  HeaWi.  09 

below  it.  It  is  evident  then  that  the  soils,  subsoils,  and  rocks  iu 
the  low-lying  districts  of  the  city  have  but  a  poor  natiu'al  drainage, 
and  that  for  a  large  portion  of  the  da}-  drainage  is  altogether 
suspended,  excei)t  from  the  more  elevated  parts  of  the  city  Into 
the  lower.  There  is  much  stagnation  of  the  water  in  the  ground. 
A  railway  which,  passing  over  the  Liifey,  connects  the  Dublin 
and  Kingstown  Eailway  with  the  Great  Northern  Railway,  has 
recently  been  constructed.  In  sinking  for  foundations  for  the 
many  bridges  required  by  this  line,  a  good  opportunity  for 
examining  the  nature  of  the  subsoils  and  rock  was  afforded,  i 
took  advantage  of  it.  I  found  that  near  the  river  tlie  deep-lying 
gravel  was  more  or  less  filled  up  Avith  mud,  which  often  possessed 
an  offensive  odour,  and  even  evolved  sulphuretted  hydrogen  gas. 
The  water  taken  from  the  excavations  was  loaded  with  organic 
matter,  and  literally  teemed  with  micro-organisms. 

Fraenkel  found  a  similar  condition  of  things  in  the  soil  of 
Berlin  near  the  river  Spree.  In  the  case  of  stagnant  water  in 
wells  he  found  that  when  first  pumped  uj)  it  contained  10,800 
microbes  per  cubic  centimetre.  After  pumping  up  500  litres 
the  number  of  microbes  fell  to  54  per  cubic  centimetre.  The 
folloAving  day,  however,  the  Avater  Avhen  pumped  up  first  had 
7,000  microbes  per  cubic  centimetre,  Avhich  number  fell  subst*- 
(juently  to  42. 

Dr.  P.  F.  Frankland,  F.R.S.,  found  that  Avater  Avliich  contained 
Avhen  collected  7  microbes  per  cubic  centimetre,  included  495,00Ci 
Avhen  kept  for  three  days. 

All  this  shoAvs  the  AA'onderful  development  of  microbian  life 
AA'hich  takes  place  in  soil-AA-ater.  But  in  the  soil  itself  aerobiaK 
and  anaerobian  organisms  are  also  present  in  Aast  numbers. 
Duclaux  found  two  millions  of  them  per  centlgi'am  of  the  uppei' 
soil.  The  lessening  of  microbial  life  as  it  proceeds  doAvnAA^ards  in 
the  earth,  is,  no  doubt,  due  chiefly  to  the  partial  deprivation  rf 
oxygen — Avhich  is  essential  to  the  life  of  many  kinds  of  bacteria — 
and  perhaps  to  lower  temperature.  The  life-history  of  the  Bacillus^ 
typhosus  is  so  little  knoAvn  that  one  can  only  speculate  as  to  it^ 
behaviour  in  the  soil.  So  far  as  Ave  can  judge,  it  belongs  to  the 
class  of  organisms  Avhich  Professor  Fliigge  terms  facultative  ancuy 
robes,  Avhicli  develop  most  rapidly  in  the  presence  of  oxygen,  but 
can  groAv  in  the  absence  of  air.  Soil  saturated  Avith  Avater,  or 
stiff  impertransible  days,  Avould  therefore  be  the  least  faA'ourablc 
for  the  development  of  the  microbe  of  typhoid  fever.     A  stud/ 


70  Report  on  Public  Health. 

of  tlie  (listribution  of  tliis  disease  in  Dublin  would  seem  to  sliow 
tliat  there  is  a  relation  between  it  and  the  ideological  character 
nf  the  soil.  Dublin  and  its  suburbs  are  built  partly  upon  stiff 
clay,  partly  upon  gravel,  resting  upon  hard  rock  or  clay.  The 
gravel  bed  was  once  the  bottom  of  the  sea,  and  now  consists  of 
raised  ancient  sea  beaches,  which  extend  along  a  considerable 
extent  of  the  eastern  coast  of  Ireland.  This  littoral  gravel  bed 
begins  from  the  north  side  of  Dollymount,  on  Dublin  Bay,  extends 
to  Drumcondra,  a  northern  suburb,  and  runs  parallel  to  the  river  in 
its  whole  course  through  the  city.  The  gravel  on  the  south  side 
of  the  city  also  runs  alongside  of  the  Liffey,  extending  at  many 
points  to  a  considerable  distance  south  of  the  river.  I  have  prepared 
a  ma])  showing  the  distribution  of  1,980  cases  of  typhoid  fever 
in  Dublin  during  the  ten  years  ended  in  1891.  That  portion  of 
the  city  which  is  situated  on  the  gravel,  or  to  use  its  geological 
designation,  "  post  tertiary  fluvio-marine  sands  and  gravel,"  is 
indicated  by  a  blue  line  on  the  map.  All  inside  this  line  is  gravel, 
all  outside  of  it  is  tlie  clay.  1,980  cases  of  typhoid  fever  have, 
so  far  as  I  can  ascertain,  occurred  in  Dublin  during  the  ten  years 
ended  in  the  year  1890.  These  cases  are  indicated  by  red  dots 
on  the  map.  Dr.  Grimshaw,  Registrar-General  for  Ireland,  has 
ascertained  the  number  of  persons  living  upon  the  gravel  and  also 
upon  the  clay.  Dividing  by  the  number  of  cases  of  typhoid  fever 
the  population  on  the  gravel  districts,  it  is  found  that  they  were 
in  the  ratio  of  one  in  every  92*8  persons.  A  similar  division  in 
reference  to  the  clay  district  shows  that  only  one  in  every  145*3 
persons  had  typhoid  fever.  It  seems,  therefore,  that  the  chances 
of  contracting  typhoid  fever  are  fifty  per  cent,  greater  on  the  gravel 
than  on  the  clay.  The  1,980  cases  of  tyjihoid  fever,  indicated  on 
the  map,  are  not  the  only  ones  which  have  occurred  in  Dublin 
since  1882  ;  but,  as  the  compulsory  notification  of  infective  diseases 
has  but  lately  come  into  operation  in  Dublin,  I  could  only  ascertain 
the  existence  of  cases  by  means  of  hospital  returns,  by  the  regis- 
tration of  deaths,  and  by  the  Reports  made  by  poor  law  medical 
officers. 

I  have  placed  in  diagram  form  the  facts  relating  to   typhoid 
fever  distribution  in  Dublin : — 


THE  fl£0  MARKS  lflDICAT£  TN£  PLACES  IN  THE  CIry  or DUBI//1 

IN  irmcH  CASES  or  typhoid  rEVE-R  occoppeo  DOt/vc  rH£r£A/>s 

/88Z'/83/   mCLUSIVE     ALL  within  the DOTFEO  i//ye,s gj^^i,^^ 
ALL  OUTSIDE  IS  CLAY 


Report  on  Public  Health. 


71 


t 

Population  of 

the  City  of 

Dublin  by  1891 

Census 

Per  cent._ 

Na  of  Persons 

affected  by 

Typhoid  Fever  in 

10  years  ended  IS'Jl 

TIatio 

of  Cases 

to  Population 

1 
No.         Per  cent. 

Living  upon  gravel  soils 
Living  upon  the  clay 

Total 

75,486 
169,615 

245,001 

30-7 
69-3 

813 
1,167 

41 

59 

1  in    92-8 
1  in  145-3 

1,980 

100 

On  the  clay  a  larger  proportion  of  the  cases  occur  over  old 
water-courses  which  have  been  filled  up  with  loose  soils.  In  Dublin 
the  gravel  for  the  most  part  rests  upon  clay  or  rock  which  retains 
Avater. 

On  the  whole,  the  distribution  of  typhoid  fever  in  the  suburbs 
resembles  that  described  for  the  city.  There  is  not  much  of  the 
gravel  in  Clontaif,  but  upon  it  most  of  the  cases  in  the  district 
occur.  The  rate  is  as  high  as  in  the  city,  whilst  the  general  an-d 
zymotic  death-rates  are  lower.  In  the  Report  to  the  War  Office 
on  the  sanitary  condition  of  the  Royal  Barracks,  Dublin,  by 
Dr.  Grimshaw,  Registrar-General,  and  myself,  Ave  pointed  out  that 
typhoid  fever  prevailed  where  the  gravel  existed. 

A  main  drainage  scheme  has  recently  been  adopted  by  the 
Corporation,  and  operations  relative  thereto  will  soon  be  com- 
menced. I  have  every  hope  that  when  in  operation  for  some 
time  it  will  materially  lessen  our  typhoid  fever  death-rate. 

Dublin  is  a  citv  with  an  undue  amount  of  typhoid  fever  in  it. 
It  is  supplied  with  pure  water  drawn  from  a  distant  source.  Its 
local  wells  have  fallen  into  disuse.  Its  street  sewers  are  as  good 
as  those  in  the  English  towns.  Like  other  places  its  milk-supplies 
may  be  now  and  then  infected  with  typhoid  poison.  In  1879  I 
found  that  63  cases  of  typhoid  fever — of  which  6  proved  fatal — 
were  caused  by  using  milk  obtained  from  a  particular  dairy.  The 
owner  of  the  dairy  and  two  of  his  children  had  fever;  and  their 
dejections  were  deposited  on  the  manure  heap  close  to  the  place 
where  the  cows  were  milked. 

The  prevalence  of  typhoid  fever  in  Dublin  in  1889  and  1891 
•was  by  many  persons  attributed  to  the  use  of  oysters;  and  for 
a  time  so  great  was  this  oyster  scare  that  the  sale  of  the  mollusc 
nearly  died  out.     In  Belfast  the  same  idea  prevailed,  but  not  so 


72  Eeport  on  Pahlk  IleolU,. 

generally.  I  may  mention  that  at  the  meeting  of  the  British 
Medical  Association  at  Cambridge  in  1881  I  read  a  paper  entitled 
''  Sewage  in  Oysters,"  in  Avhich  I  pointed  out  the  fact  that 
sewage — which  perhaps  might  contain  the  microbes  of  typhoid 
fever — was  often  present  in  oysters.  I  have  repeatedly  detected 
sewage  in  oysters  taken  from  the  shores  of  Dublin  Bay.  Oysters, 
cockles,  mussels,  and  other  lamellibranchiate  molluscs  are  often 
eaten  uncooked,  and  their  shells  enclose  a  liquid  which  is  also 
often  drank  raw.  Although  oysters  when  deserted  by  the  tide 
usually  keep  their  valves  closed,  they  do  not  invariably  do  so :  and, 
therefore,  at  low  water  sewage  trickling  down  the  shore  is  likely  to 
find  its  way  into  the  interior  of  the  oyster  and  other  shell  fish.  1 
Avould  prefer  having  oysters  taken  from  the  lonely  coasts  of  Clare 
and  Kerry  than  from  the  estuaries  of  rivers,  which  receive  the  filth 
of  large  towns. 

It  is  possible  that  vegetables  taken  from  an  infected  soil  might 
be  the  vehicle  of  the  disease.  Salad,  radishes,  and  other  esculents 
nre  often  brought  into  the  house  Avithout  having  been  separated 
from  the  soil  in  which  they  have  been  grown :  if  eaten  without 
being  perfectly  washed  they  might  introduce  the  microbe  of  typhoid 
fever  into  the  body. 

Although  infected  food  may  cause  cases  of  typhoid  fever  in 
Dublin,  it  is  not  probable  that  they  are  more  numerous  there  than 
elsewhere;  we  must,  therefore,  look  for  some  other  more  common 
source  of  the  disease  than  infected  water,  milk,  and  other  foods, 
0?  course  the  house-drains  may  be  blamed  for  the  prevalence  of  the 
disease,  I  examine,  or  cause  to  be  examined,  the  sanitary  condition 
cf  the  houses  in  which  it  occurs;  in  a  large  proportion  of  them 
defects  are  detected,  the  traps  are  out  of  order,  the  drains  are 
choked  up  with  fats  or  other  obstructions,  or  they  consist  of 
rubble — in  short,  the  usual  sanitary  defects  found  in  so  many 
liouses  when  carefully  overhauled  are  detected  in  nearly  half  of  the 
houses  examined.  On  the  other  hand,  the  disease  constantly  makes 
its  appearance  in  houses  where  no  defects  can  be  detected,  where 
the  "smoke  test"  shows  no  leak  of  drain  or  defect  of  trap,  where 
the  water-closets  are  of  the  most  recent  construction,  and  in  good 
working  order,  and  where  the  Avater  is  taken  direct  from  high 
pressure  taps.  Again,  the  disease  does  not  appear  in  houses  in 
which  for  years  the  sanitary  accommodation  and  drains  have  been 
imperfect. 

It  is  admitted  that  there  has  been  a  great  improvement  during 


lieport  0)1  Publir  Health.  1',\ 

recent  years  in  the  construction  of  house  drains,  and  the  old  ''built" 
sewers  have  been  all  but  completely  replaced  by  earthenware  pipes, 
laid  in  cement.  As  I  have  already  stated,  the  zymotic  death-rate  has 
greatly  declined,  but  still  typhoid  fever  more  than  holds  its  own. 
I  can  only  account  for  this  by  assuming  that  the  microbes  of  the 
disease  have  established  themselves  in  the  soil,  that  they  multiply 
therein,  and  that  they  issue  occasionally  from  it  into  the  atmosphere, 
which,  consequently,  becomes  infected.  It  is  only  in  this  way  that 
we  can  reasonably  account  for  the  periodic  character  of  the  disease, 
for  its  seasonal  intensity,  for  its  epidemics.  It  may  be  said  as 
against  this  view  that  we  have  epidemics  of  small-pox,  scarlet  fever, 
measles,  and  so  on ;  but  these  diseases  are  directly  communicable 
from  person  to  person,  whereas  that  is  not  the  case  with  typhoid 
fever.  The  "w.c.s,  house  drains,  and  street-sewers  do  not  vary 
much  from  year  to  year,  and  when  they  do  vary  it  is  generally 
because  they  are  improved.  In  the  soil,  therefore,  we  must  look 
for  the  cause  of  the  endemicity  of  typhoid  fever  in  Dublin  and  in 
other  places.  This  theory  is  greatly  strengthened  by  the  fact  that 
the  porous  soils  are  to  a  much  greater  extent  likely  to  be  the  habitat 
of  the  organism  than  the  stiff  clays.  The  conditions  of  existence  for 
all  kinds  of  organisms  are  more  favourable  in  loose  soils  than  in 
adhesive  dense  clays,  in  which  air  cannot  freely  circulate.  The 
action  of  strong  winds,  and  the  rising  and  sinking  of  underground 
Avater,  more  readily  cause  movements  of  air  in  gravels  and  loose 
soils  than  in  clays;  and  the  escape  of  microbes  from  the  former 
under  such  circumstances  must  the  more  freely  occur.  The  streets 
of  Dublin  have  lately  been  to  a  large  extent  paved  with  stone 
setts,  which  circninstance  may,  perhaps,  account  to  some  extent 
for  the  increase  of  typhoid  fever.  The  underground  air  cannot  now- 
diffuse  into  the  atmosphere  over  the  roadway,  and  therefore  may 
be  drawn  in  larger  quantities  into  the  houses,  the  basement  floors 
of  which  are  rarely  concreted. 

The  question — how  do  the  microbes  of  typhoid  fever  ascend 
from  the  soil  into  the  atmosphere  %  is  one  that  cannot  be  answered 
off-hand.  Vegetable  organisms  that  exist  in  the  superficial  layers 
of  soil  are  easily  detached  by  strong  winds,  and  carried  into  the 
air.  The  malarial  poison,  which  is  clearly  derived  from  the  soil, 
can  be  transferred  to  the  air;  but  probably  it  exists  on  or  near 
the  surface.  If  the  typhoid  bacillus  is  deep-seated  amidst  the 
decomposing  organic  matter  of  the  soil,  it  can  only  with  difficulty 
reach  the  surface.     So  lonii-  as  the  ground  is  thorouffhlv  wet  the 


74  Report  on  Public  Health. 

organisms  will  remain  tlicro.  When  the  upper  layers  of  soil 
become  quite  dry,  the  organisms  in  them  undergo  a  species  of 
desiccation,  and  in  that  state  they  are  easily  transportable  to  the 
air  by  the  agency  of  the  forces  acting  upon  the  subterranean 
atmosphere  to  which  I  have  already  referred.  When  they  are 
completely  desiccated,  the}^  are  probably  innocuous ;  but  they 
may  sometimes  reach  the  air  without  being  deprived  of  all  their 
moisture.  The  spores  of  the  bacillus  may  also,  from  their  extreme 
minuteness  and  lightness,  be  carried  up  from  the  soil  by  air- 
currents. 

Hoffmann^  has  pointed  out  that  there  is  in  porous  soils  -what 
he  terms  a  superficial  zone  of  evaporation,  in  which  the  moisture 
varies  from  saturation  to  zero.  In  the  hot  summer  weather  the 
zone  is  considerable  in  extent,  and  when  rain  descends  on  it,  after 
a  period  of  heat  and  drought,  it  is  often  capable  of  retaining  the 
whole  of  the  Avater  without  its  lower  border  becoming  wet.  In 
such  there  is  always  a  dry  layer  between  the  surface  part,  which 
is  temporarily  wetted  by  the  rain,  and  the  deeper  strata  in  which 
the  Avater  lies.  Under  these  conditions  the  impurities  wdiich  reach 
the  soil  become  deposited  in  the  dry  zone ;  under  this  zone  is 
situated  a  layer  whicli  is  always  Avet.  When  the  upper  zone  is 
filled  Avith  rain  the  amount  of  water  in  the  second  zone  remains 
constant,  for  any  excess  AA'hich  it  may  receive  passes  doAvn  into 
the  third  zone,  or  that  of  the  underground  AA'ater.  If  the  typhoid 
bacillus  exists  in  the  first  zone,  it  must  alternately  be  immersed 
in  Avater  and  in  air.  In  the  former  case  it  remains  in  the  soil, 
in  the  latter  it  may  be  transported  to  the  atmosphere  by  air- 
currents.  The  deeper  the  ground-Avater  sinks,  the  greater  aaIII 
be  the  extent  of  the  zone  in  Avhich  the  movements  of  organisms 
can  take  place ;  but  even  Avhilst  the  ground- Avater  is  sinking,  the 
outermost  layer  of  soil  may  be  kept  moist  by  slight  and  long- 
<-ontinued  rain.  In  this  case,  hoAvcAcr  large  the  dry  zone,  none  of 
its  organisms  Avould  escape  from  it  into  the  air. 

During  the  Avinter  ami  early  months  of  the  year  the  surface  soil, 
and  often  all  the  layers  beneath  it,  are  so  Avet  that  but  fcAV,  if 
any,  organisms  can  escape  from  it.  There  is  A-ery  little  difference 
in  Dublin  betAveen  ihe  rainfall  of  the  different  quarters  of  the 
year,  but  in  the~sunnner  the  water  Avhich  falls  upon  the  ground  is 
not  only  carried  off  by  drainage,  but  it  is  largely  evaporated.  In 
the  latter  part  of  summer,  and  in  the  autumn,  the  superficial 

"  Archiv  fiir  Hygiene.     Vcls.  I.  and  II.     Part  II. 


Report  on  Public  Health.  75 

layers  of  soil  often  become  sufficiently  dry  to  permit  of  the  passage 
through  them  of  micro-organisms.  The  autumn  and  early  winter 
are  the  periods  during  Avhich_t}^3lioid  fever  attains  its  maximum, 
and  the  majority  of  writers  on  the  subject  agree  that  the  disease 
often  becomes  epidemic  after  an  unusually  hot  and  dry  summer. 

I  admit  that  the  chances  of  detaching  micro-organisms  from 
moist  surfaces  are  slight,  but  it  must  occur  now  and  again.  Those 
of  typhoid  fever  have  not,  I  believe,  been  detected  yet  in  the 
atmosphere,  but  pus  organisms  and  the  microbes  of  diphtheria 
have. 

A  very  fascinating  theory  is  that  which  assumes  that  the  micro- 
oi'ganisms  which  cause  disease  are  saprophytes  which  have  acquired, 
under  at  present  unknown  conditions,  toxic  properties.  This  theory 
fits  in  better  Avith  our  knowledge  of  malaria  and  typhoid  fever 
than  with  that  of  most  of  the  other  zymotic  diseases.  It  would, 
perhnps,  account  for  the  great  variety  of  forms  which  the  disease 
assumes.  In  the  United  States  of  America  malarial  fevers  are 
lessening  because  the  cultivation  of  the  soil  is  extending ;  but  the 
increase  of  population  in  that  country  is  producing  a  greater 
development  of  typhoid  fever.  There  are  cases  of  fever  met  with 
constantly  Avhich  almost  resemble  typhoid  fever,  but  still  have 
some  points  of  resemblance  to  malaria,  and  vice  versa.  Lomstaud- 
Chatenet^  has  described  some  remarkable  cases  of  typhoid  fever 
which  seem  to  have  had  a  malarial  origin. 

There  is  quite  a  literature  of  the  so-called  typho-malai'ial  fever, 
which  one  can  hardly  peruse  without  coming  to  the  conclusion 
that  at  least  in  the  aetiology  of  typhoid  fever  and  of  malaria  there 
are  very  striking  analogies.  New  arrivals  in  a  country  where 
malaria  exists  are  the  least  likely  to  escape.  The  same  observa- 
tion in  reference  to  typhoid  fever  has  been  mentioned  by  Murchison. 
In  India  the  young  soldiers  on  their  arrival  are  peculiarly  liable 
to  contract  the  disease. 

"  Sur  la  forme  palustre  de  la  fievre  tyi)lioide.     Paris.     1 S70. 
(To  he  continued.) 


PART  IV. 
MEDICAL  MISCELLANY 


Bejjorts,  Transactions ^  and  Scientific  TnteUiaence. 


ROYAL    ACADEMY    OF    MEDICINE    IN    IKELAND. 

President— George   H.  Kidd.  M.D.,  F.R.C.S.I. 
General  Secretary — W.  Thomson.  F.R.C.S.I. 


SECTION    OF    MEDICINE. 

President — J.  Mauee  Fixny,  M.D.  ;  President  of  the  Royal  College  of 

Physicians  of  Ireland. 

Sectional  Secretary — A.  N.  Montgomery,  M.R.C.P.T. 

Friday,  April  22,  1S02. 

Dr.  J.  Hawtrey  Ben.son  in  the  Cluiir. 

The  Desirabi/iti/  of  Operative  Interference  in  Suspected  Perforatioi  (f 
Chronic  Ulcer  of  the  Stomach. 

Dr.  Parsons  read  a  paper  on  the  desirability  of  operative  interference 
in  suspected  perforation  of  chronic  ulcer  of  the  stomach.  [It  will  he 
found  at  page  2G.] 

Mr.  M'Ardle  said  that  Dr.  Parsons  must  not  contrast  operations  for 
injury,  pelvic  abscess,  or  ruptured  ovarian  cyst,  with  that  for  chronic 
perforations,  since  in  these  cases  (as  in  one  of  those  mentioned  in  this 
paper)  the  margin  of  the  perforation  is  so  soft  that  sutures  'vvill  not  hold, 
Avhile  in  those  cases  of  injuiy  the  edges  of  the  wound  are  healthy  and 
permit  of  suture.  The  other  cases  do  not  interfere  materially  Avith  vital 
organs,  and  so  should  not  be  brought  iuto  the  question.  It  is  doubtful  if 
Lcmbert's  suture  will  ever  be  found  effectual  in  closing  perforating 
ulcers  of  the  stomach,  and  the  delay  occasioned  by  the  application  of 
this  suture  would  in  itself  prove  fatal  to  a  patient  already  in  a  state  of 
collapse.  It  seemed  to  the  speaker  that  the  introduction  of  a  large  bone- 
plate  thiougli  the  stomach  wound,  sutures  from  this  plate  through  the 
.stomach  wall,  and  out  through  the  anterior  abdominal  wall,  would  secure 


Si-ction  of  Med  lev  te.  11 

tlie  stomach  torwards,  thus  establishing  a  fistula.  Tliis  operation  would 
occupy  from  20  to  30  minutes,  as  in  similar  operations  on  the  intestines, 
while  resection  of  the  edges  of  the  ulcer  and  suture  after  Lembert's 
method  must  occupy  a  time  sufficient  to  prevent  a  favourable  result. 
Should  Ave  succeed  in  reducing  the  time  required  for  the  operation,  and 
sliould  the  cases  come  under  treatment  before  exhaustion  or  sepsis  occurs, 
such  success  may  be  hoped  for  as  attends  laparotomy  for  other  than 
perfoi-ative  peritonitis. 

Dn.  O'Carroll  agreed  that,  in  cases  which  can  be  certainly  diagnosti- 
cated as  cases  of  perforation  of  stomach,  operation  is  desirable.  But  it 
was  inevitable  that  a  large  number  of  abdominal  sections  would  be  done 
without  finding  the  perforation,  and  still  more  without  being  able  to  do 
anything  of  advantage  to  the  patient.  There  were  difiiculties  in  diagnosis 
A\hich  had  yet  to  be  got  over — namely,  the  recognition  of  perforation  in 
cases  in  which  a  false  stomach  has  been  formed  by  peritoneal  adhesions, 
and  in  which  the  fatal  perforation  has  occurred,  and  the  differentiation 
of  gastric  perforation  from  many  cases  of  acute  and  subacute  gastritis 
simulating  it.  Of  course  there  remains  the  wider  difiiculty  of  being  sure 
that  the  perforation  is  a  gastric  one  at  all. 

Dr.  "Walter  Smith  alluded  to  the  gi"ave  responsibility  which  now  so 
often  devolves  upon  the  physician  of  advising  for  or  against  operative 
interference  in  cases  of  acute  intra-abdominal  inflammation.  Speaking 
from  his  own  experience,  he  could  confidently  say  that  in  no  single  case, 
even  when  the  issue  was  fatal,  liad  he  reason  to  regret  having  called  for 
surgical  intervention. 

Dr.  J.  W.  Moore  agreed  with  Dr.  Walter  Smith  in  his  views  as  to 
the  interdependence  of  medicine  and  surgery,  but  was  glad  to  observe 
that,  Avhile  thus  expressing  himself,  Dr.  Smith  was  careful  to  avoid  any 
suggestion  that  a  physician  should  practise  surgery  or  a  surgeon  medicine. 
Dr.  Moore  recalled  how  closely  the  subjective  sensations  of  improvement 
experienced  by  the  victim  of  perforation  after  some  hours  resembled  the 
mental  state,  amounting  to  euthanasia,  often  observed  in  those  dying  of 
malignant  smallpox  of  the  piu'puric  or  ha3morrhagic  variety.  The  success 
of  laparotomy  in  cases  of  perforation  in  enteric  fever  was  very  encourag- 
ing. Up  to  the  close  of  2sovember,  1891,  19  cases  with  4  recoveries 
had  l)ceu  recorded.  This  represented  a  percentage  of  recovery  of  more 
than  20  per  cent — no  small  gain  in  the  case  of  the  most  perilous  of  all 
the  complications  of  enteric  fever. 

Dr.  C.  F.  Moore  could  not  say  Avhether  present  experience  throws 
;my  light  in  the  way  of  comparative  pathology  on  the  question  of  perito- 
nitis from  injuries  or  disease.  He  had  once  examined  the  abdomen  of  a 
ten-foot  crocodile  and  found  there  several  stones  cucapsuled  in  fibrous 
tissue  and  hanging  thereby  from  diiferent  parts  of  the  alimentary 
canal.     Some  of  these  foreign  bodies  were  as  large  as  a  small  closed 


78  Royal  Acadenn/  of  Medicine  in  Ireland. 

fist,  and  had  evidently  been  extruded  witliout  injuriug  tlie  healtli  of  tlie 
auimal. 

Dr.  Parsons  replied. 

Detachment  of  Retina. 

Mr.  Story  read  notes  of  three  cases  of  detached  retina  in  myopic 
eyes,  which  had  either  partially  or  completely  recovered.  In  one  case 
complete  cure  had  taken  place  after  rest  in  bed  with  bandaging  and  the 
use  of  atropin  drops.  In  the  second  a  permanent  improvement  had 
residted  from  similar  treatment,  leaving  a  useful  e^e,  which  had  now- 
existed  for  14  years.  In  the  third  the  detachment  was  complicated  with 
keratitis  punctata  and  glaucoma,  and  subsided  completely  seven  weeks 
after  the  operation  of  sclerotomy. 

Mr.  Sw'ANZV  stated  that  Mr.  Story's  experience  of  the  treatment  of 
detached  retina  coincided  very  much  Avith  his  own.  A  case  of  the 
disease  does  occasionally  get  well  under  ti'eatment,  or  seem  to  do  so.  It 
is,  hoAvever,  a  question,  whether  the  treatment  has  had  much  to  do  w^th 
the  case.  A  lady  consulted  Mr.  Swanzy  some  years  ago,  and  being 
unable  to  place  herself  under  the  lengthened  treatment  required,  returned 
home  to  the  country.  After  a  year  she  presented  herself  again,  Avhen 
Mr.  Swanzy  found  that  the  detachment  had  quite  gone  back  and  the  eyo 
was  perfectly  normal.  Treatment,  therefore,  may  have  little  to  do  with 
the  apparent  cures  by  any  of  the  various  methods  proposed. 

The  Section  then  adjourned. 


SECTION    OF    SURGERY. 

President — IT.   G.  Ckolv,  President  of  the  Royal  College  of  Surgeons 

in  Ireland. 

Sectional  Secretary — R.  L.  Savax,  F.R.CS.I. 
Friday,  May  20,  ISO:?. 
Sir  W.  Stokks  in  the  Chair. 

Trephining  in  Cevehral  Meningitis. 

Mr.  M'Ardle  read  his  paper  entitled  "Trephining  in  Cerebral  Menin- 
gitis."    [It  will  be  found  at  page  17.] 

The  Chairman  (Sir  William  Stokes)  observed  that,  in  his  opinion, 
Mr.  M'Ardle's  communication  Avas  one  of  gi'eat  importance  in  connection 
with  the  subject  of  brain  surgery,  Avhich  for  some  years  has  been,  and 
still  is,  engaging  the  attention  of  surgeons.  He  agreed  Avith  Mr.  M'Ardle's 
remarks  in  reference  to  the  operation  of  trephining  acting  as  a  preA'cntive 
meanu-e  to  the  occurrence  of  inflammatoi-y  troubles  subsequently  super- 


Section  of  Surgerij.  79 

vening.  His  experience  goes  a  long  way  to  confirm  the  views  of  the  older 
surgeons  in  reference  to  the  value  of  trephining  as  a  means  of  preventing 
inflammatory  complications  after  cranial  injuries.  Mr.  M'Ardle's  I'cmarks 
as  to  the  necessity  of  accurately  determining  by  careful  raeasurem.ents 
the  appropriate  situation  whei*e  the  operation  should  be  performed  were 
of  the  greatest  importance. 

Mr.  Tobix  referred  to  a  case  somewhat  similar  to  that  of  Mr.  M'Ardle's, 
in  which  he  got  a  successful  result  after  trephining  and  draining  away  a 
quantity  of  serum  underlying  the  dura  mater,  and  gave  it  as  his  opinion 
that  tubercular  meningitis  might,  in  a  considerable  number  of  cases,  be 
successfully  treated  if  they  were  freely  drained  at  an  early  stage. 

Mr.  J.  H.  Scott  said  two  minor  points  in  this  case  appear  of  some 
importance.  Fii'st,  Avhy  Avas  mercury  administered?  He  considered 
mercury  had  no  effects  on  any  inflammatory  effusions  except  those  of  a 
syphilitic  origin.  Secondly,  the  apparent  osseous  closure  of  the  trephine 
opening  without  replacement  of  the  removed  bone.  He  thought  it  pro- 
bable the  osseous  development  was  due  to  some  of  the  superficial  osteo- 
clasts adhering  to  the  detached  dura  mater. 

Me.  M'Ardle  was  sorry  that  he  cuuld  not  elicit  an  explanation  of  the 
change  of  pulse  noted  by  Mr,  Patteson.  The  speaker's  opinion  was  that 
the  working  of  the  trephine  stimulated  those  centres  which  the  pressure 
of  the  fluid  prevented  from  action  without  strong  stimulation.  In  the 
case  detailed  by  Mr,  Tobin  the  chief  symptoms  wei'e  the  same  as  in  the 
case  noted,  but  the  deviation  of  the  eyes  was  in  the  opposite  direction. 
The  difference  is  easily  explained  in  Mr.  Tobin's  case — the  pressure  was 
not  sufficient  to  check  the  action  of  the  centres  on  the  injured  side,  but 
the  irritation  of  these  centres  would  have  the  effect  noted.  Mr.  M'Ardle, 
replying  to  Mr.  Scott,  said  he  used  mercury  in  this  case  because  in  veiy 
many  non-S}^hilitic  "oflammations,  meningeal  and  otherwise,  great  benefit 
resulted.  In  reply  to  Mr.  Cox,  Mr.  M'Ardle  said  he  would  not  operate 
on  cases  in  which  the  meningeal  trouble  Avas  secondary  to  some  rapidly- 
progressing  fatal  aifection,  or  in  chronic  alcoholism  where  fibroid  dege- 
neration of  important  organs  was  present.  The  speaker  begged  to  thank 
Sir  William  Stokes  for  his  support  of  the  opinion  that  trephining  should 
have  been  tried  in  the  first  case  related. 

Ekctrolysis  in  Affections  of  iJte  Male  Urelhra. 

Dr.  Pearson  read  a  paper  on  the  uses  of  electrolysis  in  affections  of 
the  male  urethra. 

(1,)  Introciuction  to  the  subject  of  urethral  electrolysis, 
(2,)  Description  of  apparatus  I'Cc^uired  for  its  employment, 
(3,)  Description  of  its  method  of  employment  in  cases  of  gleet,  stric- 
ture, &c, 
(4.)  History  of  seven  cases  subjected  to  electrolytic  treatment. 


so  Roi/al  Academy  of  Medicine  in  Ireland. 

(5.)  Deductions  from  its  employment  in  these  cases. 

(G.)  General  conclusions  regarding  its  uses. 

Sir  Wii.LiA^i  Stokes  congratulated  the  author  on  the  iutei'est  and 
importance  of  his  communication.  He  could  not,  hoAvever,  endorse  what 
Jiad  fallen  from  the  author  in  reference  to  the  permanence  of  the  cure  of 
stricture  by  electrolysis.  In  fact,  in  Sir  W.  Stokes'  opinion,  after  no 
method  of  treatment  can  it  be  honestly  said  that  a  cure  has  been  effected, 
and  in  his  experience  a  return  was  just  as  likely  to  occur  as  after  the 
treatment  by  internal  or  external  division  or  gradual  dilatation.  In  the 
treatment  of  gleet,  Sir  W.  Stokes  thought  that  Dr.  Pearson's  experience 
should  stimulate  surgeons  to  give  it  a  full  trial. 

Mu.  Thomson  said  he  had  used  the  method  described  by  Dr.  Pearson 
in  n^leet  with  success.  But  his  experience  in  stricture  was  not  satisfac- 
tory, and  he  had  not  pursued  the  treatment.  He  was  acquainted  with 
Dr.  Newman's  claims,  and  the  work  that  had  been  done  by  Dr.  Slcavenson. 
But  if  the  treatment  was  so  successful  as  was  claimed,  was  it  not  curious 
that  all  surgeons  the  world  over  did  not  adopt  it.  The  question  was 
i-eally — Was  stricture  of  the  urethra  curable  ?  He  (Mr.  Thomson)  had 
never  seen  a  case  Avhere,  no  matter  what  method  was  adopted,  he  was 
-able  to  say  to  a  patient :  You  are  cured — that  is,  that  the  person  could 
"O  on  without  the  periodical  use  of  a  bougie.  lie  had  never  met  anyone 
who  claimed  such  a  result.  Was  it  attainable  by  electrolysis  ?  If  it  was, 
thev  ought  all  to  adopt  this  plan,  but  until  such  a  claim  could  he  sub- 
stantiated he  did  not  think  that  electrolysis  had  any  advantage  over  some 
of  the  simpler  methods. 

Mr.  Savan  said  that,  for  his  part,  he  did  not  believe  in  the  permanent 
cure  of  sti'icture  by  electrolysis,  no  more  than  he  believed  in  the  same 
result  by  Holt's  method,  by  gradual  dilatation,  or  by  any  form  of  ure- 
throtomv.  He  remembered,  Avhen  Holt's  method  was  in  fashion,  it  Avas 
thou«'ht  that  stricture  was  at  last  conquered.  Many  persons,  he  believed, 
were  Holted  (if  he  might  use  the  term)  who  never  had  stricture.  Only 
last  month  he  had  used  Maisonneuve's  instrument  on  a  gentleman,  the 
possessor  of  a  tight  stricture,  Avho  had  been  cured  for  a  time  by  electro- 
lysis. 

'Mn.  M'Ardle  said  the  only  experience  he  had  of  this  treatment  for 
stricture  was  that  he  Iiad  been  obliged  to  use  Maisonneuve  very  frequently 
on  cases  of  so-called  cures  by  electricity.  As  to  the  good  effect  of  the 
application  of  the  electric  current  to  patches  of  granular  urethritis  and 
small  patches  of  ulceration,  there  can  be  no  doubt,  and  if  large  leaden 
<'leclrodes,  carefully  guarded,  were  used,  the  healing  should  be  more 
rapid. 

Mr.  ToiiiN  said  the  question  of  the  permanent  cure  of  stricture  by 
electrolysis  resolves  itself  into  this — Can  electrolysis  cause  the  disappear- 
ance of  cicatricial  tissue?    His  opinion  was  that  it  cannot.    However,  on 


i 


Section  of  Surgery.  81 

hearinj;  the  excellent  paper  ju?t  read,  he  should  again  try;  and  the  case 
he  should  select  would  be  one  of  stricture  at  the  orifice  of  the  urethra. 
If  it  then  succeeds,  if  it  causes  the  disappearance  of  a  stricture  that  he 
could  see,  then  he  should  believe  in  it,  and  extend  its  application  to  all 
cases  that  he  met  with. 

The  Section  then  adjourned. 


SIMPLE    URINARY   TESTS. 

Dr.  Austin  Flint  writes  {Medical  News,  Philadelphia,  Jan.  9th,  1892) : — 
"  I  have  had  constructed  a  tube,  with  an  arbitrary  graduation  up  to  100. 
In  a  test-tube  of  convenient  size,  I  boil  a  little  more  than  half  a  fluid- 
ounce  of  urine,  to  which  have  been  added  four  or  five  drops  of  ordinary 
acetic  acid.  If  the  urine  be  turbid,  it  may  be  filtered  before  being  boiled. 
After  thorough  boiling  and  allowing  the  urine  to  cool  for  two  or  three 
minutes,  it  should  be  well  shaken,  in  order  to  divide  the  precipitated 
albumen  as  finely  as  possible,  and  then  the  graduation  tube  is  filled  to 
the  100  mark.  After  12  hours'  standing  the  percentage  of  precipitate  is 
noted.  The  albumen  will  settle  in  twelve  hours,  and  the  volume  of  the 
deposit  is  not  sensibly  diminished  if  it  be  allowed  to  stand  for  twenty- 
four  hours.  The  proportion  of  albumen  measured  in  this  way  should  be 
called  the  percentage  in  volume  of  undried  albumen.  This  method  is  not 
exactly  accurate,  but  it  is  suflficiently  so  for  ordinary  purposes.  It  will 
indicate  fairly  well  a  proportion  of  1  or  2  per  cent,  of  albumen.  When 
the  proportion  is  less  than  1  per  cent.,  the  ordinary  method  by  contact  or 
by  simple  boiling  with  a  few  drops  of  acetic  acid  would  indicate  '  a  trace ' 
of  albumen.  While  writing  upon  this  subject,  I  am  led  to  describe  a 
simple  apparatus  for  detecting  the  presence  of  sugar  in  the  urine,  when 
the  results  of  Fehling's  test  are  uncertain.  A  small  straight  bottle  or  a 
small  test-tube  is  fitted  with  a  cork,  through  which  is  passed  a  small 
tube  that  reaches  nearly  to  the  bottom.  The  glass  tube  is  bent  so  that 
the  apparatus  will  hang  over  an  ordinary  test-tube  or  other  convenient 
vessel.  The  bottle  is  completely  filled  with  urine,  with  which  a  piece  of 
Fleischmann's  yeast,  about  the  size  of  a  pea,  has  been  thoroughly  mixed. 
In  putting  in  the  cork,  it  is  necessary  to  be  careful  to  exclude  every 
bubble  of  air.  If  the  apparatus  be  kept  for  a  half  hour  at  a  temperature 
of  from  80°  to  90°  F.,  a  bubble  of  gas  will  appear  if  sugar  be  present  in 
the  smallest  quantity.  The  apparatus  may  be  placed  in  the  sun  or  near 
a  heater,  but  the  temperature  should  not  be  higher  than  100".  This  is 
valuable  as  a  negative  test.  In  case  of  doubt  I  have  often  been  able 
to  determine  absolutely  the  presence  or  absence  of  sugar  before  1  had 
finished  taking  the  history." 


G 


SANITARY     AND     METEOROLOGICAL     NOTES. 

Compiled  by  J.  W.  Moore,  B.A.,  M.D.,  Univ.  Dubl. ;  F.R.C.P.L  ; 
F.  R.  Met.  Soc. ;  Diplomate  in  State  Medicine  and  ex-Sch.  Trin.  Coll,  Dubl. 

Vital  Statistics 

For  four  Weeks  ending  Saturday,  May  21,  1892. 

The  deaths  registered  in  each  of  the  four  weeks  in  the  sixteen 
principal  Town  Districts  of  Ireland,  alphabetically  arranged,  corre- 
sponded to  the  following  annual  rates  per  1,000: — 


Towns 

Weeks  ending 

Towns 

Weeks  ending 

April 
30. 

May 

7. 

May 
14. 

May 
21. 

April 
30. 

May 

7. 

May 
14. 

May 
21. 

Armagh  - 

0-0 

0-0 

7-0 

21-0 

Limerick     - 

32-3 

25-3 

19-6 

154 

Belfast    - 

26-1 

29-3 

28-3 

23-6 

Lisburn 

12-8 

21-4 

34-3 

4-3 

Cork       - 

33-2 

30-4 

22-1 

27-7 

Londonderry 

25-1 

110 

26-7 

15-7 

Drogheda 

79-1 

22-0 

39-5 

13-2 

Lurgan 

22-8 

31-9 

22-8 

31-9 

Dublin    - 

42-8 

32-1 

29-7 

33-3 

Nevsnry 

44-3 

121 

8-1 

20-1 

Dundalk- 

12-6 

4-2 

8-4 

12-6 

Sligo 

36'1 

67-0 

361 

87-7 

Galway  - 

22-7 

15-1 

22-7 

26-4 

Waterford  - 

20-0 

17-5 

400 

10-0 

Kilkenny 

4-7 

23-6 

33-0 

28-3 

Wexford     - 

58-7 

31-6 

31-6 

45-2 

In  the  week  ending  Saturday,  April  30,  1892,  the  mortality  in  thirty- 
three  large  English  towns,  including  London  (in  which  the  rate  was 
19*8),  was  equal  to  an  average  annual  death-rate  of  20*8  per  1,000 
persons  living.  The  average  rate  for  eight  principal  towns  of  Scotland 
was  21*3  per  1,000.  In  Glasgow  the  rate  was  23*8,  and  in  Edinburgh 
it  was  21 '4. 

The  average  annual  death-rate  represented  by  the  deaths  registered 
during  the  week  in  the  sixteen  principal  town  districts  of  Ireland  was  33*9 
per  1,000  of  the  population  (unrevised)  according  to  the  recent  Census. 

The  deaths  from  the  principal  zymotic  diseases  in  the  sixteen  districts 
were  equal  to  an  annual  rate  of  3*9  per  1,000,  the  rates  varying  from 
0-0  in  eight  of  the  districts  to  16*1  in  Newry — the  11  deaths  from  all 
causes  registered  in  that  district  comprising  4  from  whooping-cough. 
Among  the  128  deaths  from  all  causes  registered  in  Belfast  are  8  from 
xueasles  (a  decrease  of  10  as  compared  with  the  number  for  the  preceding 


Sanitary  and  Meteorological  Azotes.  83 

WBek),  1  from  scarlatina,  1  from  whooping-cough,  1  from  diphtheria,  2 
from  enteric  fever,  and  1  from  diarrhoea.  The  48  deaths  in  Cork  com- 
prise 4  from  measles,  2  from  typhus,  and  2  from  whooping-cough.  The 
18  deaths  in  Drogheda  comprise  2  from  typhus  and  1  from  enteric  fever. 

In  the  Dublin  Registration  District  the  registered  births  amounted  to 
246 — 131  boys  and  115  girls;  and  the  registered  deaths  to  294 — 127 
males  and  167  females. 

The  deaths,  which  are  101  over  the  average  number  for  the  correspond- 
ing week  of  the  last  ten  years,  represent  an  annual  rate  of  mortality  of 
4o*9  in  every  1,000  of  the  population.  Omitting  the  deaths  (numbering 
7)  of  persons  admitted  into  public  institutions  from  localities  outside  the 
disti'ict,  the  rate  was  42*8  per  1,000.  During  the  first  seventeen  weeks 
of  the  current  year  the  death-rate  averaged  37"8,  and  was  6*0  over  the 
mean  rate  in  the  corresponding  period  of  the  ten  years  1882-1891. 

The  number  of  deaths  from  zymotic  diseases  registered  is  37,  being  13 
in  excess  of  the  average  for  the  corresponding  week  of  the  last  ten  years, 
but  18  under  the  number  for  the  week  ended  April  23.  The  37  deaths 
comprise  20  from  measles  (being  13  under  the  number  from  that  cause 
for  the  preceding  week),  1  from  influenza,  11  from  whooping-cough,  1 
from  diphtheria,  1  from  enteric  fever,  and  1  from  dysentery. 

Eighty-six  cases  of  measles  were  admitted  to  hospital,  being  13  in 
excess  of  the  admissions  for  the  preceding  week,  but  3  under  the  number 
for  the  week  ended  April  16.  Sixty-seven  measles  patients  were  dis- 
charged, 3  died,  and  190  remained  under  treatment  on  Saturday,  being 
16  over  the  number  in  hospital  at  the  close  of  the  preceding  week. 

The  hospital  admissions  for  the  week  include,  also,  4  cases  of  enteric 
fever  and  two  cases  of  scarlatina,  but  no  cases  of  typhus  were  received. 
Twenty-two  cases  of  enteric  fever,  13  of  scarlatina,  and  1  of  typhus 
remained  under  treatment  in  hospital  on  Saturday. 

Deaths  from  diseases  of  the  respiratory  system  amount  to  86,  being  40 
over  the  number  for  the  preceding  week,  and  46  in  excess  of  the  average 
for  the  17th  week  of  the  last  ten  years.  They  comprise  27  from  bron- 
chitis, 37  from  pneumonia  or  inflammation  of  the  lungs,  2  from  croup, 
and  2  from  pleurisy. 

In  the  week  ending  Saturday,  May  7,  the  mortality  in  thirty-three 
large  English  towns,  including  London  (in  which  the  rate  was  18*9), 
was  equal  to  an  average  annual  death-rate  of  19'7  per  1,000  persons 
living.  The  average  rate  for  eight  principal  towns  of  Scotland  was  21*4 
per  1,000.  In  Glasgow  the  rate  was  23*7,  and  in  Edinburgh  it  was 
17-3. 

The  average  annual  death-rate  in  the  sixteen  principal  town  districts 
of  Ireland  was  28*5  per  1,000  of  the  population  (unrevised)  according  to 
the  recent  Census. 


84  Sanitary  and  Meteorological  Notes. 

The  deaths  from  the  principal  zymotic  diseases  in  the  sixteen  districts 
were  equal  to  an  annual  rate  of  5*5  per  1,000,  the  rates  varying  from 
O'O  in  nine  of  the  districts  to  15*5  in  Sligo — the  13  deaths  from  all 
causes  registered  in  that  district  comprising  1  from  simple  continued 
fever  and  2  from  diarrhoea.  Among  the  144  deaths  from  aU  causes 
registered  in  Belfast  are  21  from  measles  (an  increase  of  13  as  compared 
with  the  number  for  the  preceding  week),  1  from  scarlatina,  5  from 
whooping-cough,  2  from  diphtheria,  1  from  simple  continued  fever,  2 
from  enteric  fever,  and  3  from  diarrhoea.  The  44  deaths  in  Cork  com- 
prise 1  from  measles,  1  from  typhus,  and  3  from  whooping  cough.  The 
5  deaths  in  Drogheda  comprise  2  from  typhus. 

In  the  Dublin  Registration  District  the  registered  births  amounted  to 
193 — 106  boys  and  87  girls;  and  the  registered  deaths  to  221 — 105 
males  and  116  females. 

The  deaths,  which  are  28  over  the  average  number  for  the  correspond- 
ing week  of  the  last  ten  years,  represent  an  annual  rate  of  mortality  of 
33*0  in  every  1,000  of  the  population.  Omitting  the  deaths  (numbering 
6)  of  persons  admitted  into  public  institutions  from  localities  outside 
the  district,  the  rate  was  32'1  per  1,000.  During  the  first  eighteen 
weeks  of  the  current  year  the  death-rate  averaged  37'5,  and  was  5"9 
over  the  mean  rate  in  the  corresponding  period  of  the  ten  years  1882- 
1891. 

Fifty-three  deaths  from  zymotic  diseases  were  registered,  being  33  in 
excess  of  the  average  for  the  corresponding  week  of  the  last  ten  years, 
and  16  over  the  number  for  the  week  ended  April  30.  They  comprise 
40  from  measles  (being  20  over  the  number  from  that  cause  for  the 
preceding  week),  2  from  influenza  and  its  complications,  4  from  whooping- 
cough,  1  from  diphtheria,  and  2  from  diarrhoea. 

The  number  of  cnses  of  measles  admitted  to  hospital  is  57,  being  a 
decline  of  29  as  compared  with  tlie  admissions  for  the  preceding  week, 
and  16  below  the  admissions  for  the  week  ended  April  23.  Sixty-eight 
measles  patients  were  discharged,  5  died,  and  174  remained  under  treat- 
ment on  Saturday,  being  16  under  the  number  in  hospital  at  the  close  of 
the  preceding  week. 

The  hospital  admissions  for  the  week  include,  also,  4  cases  of  enteric 
fever,  4  of  scarlatina,  and  2  cases  of  typhus.  Twenty-one  cases  of 
enteric  fever,  16  of  scarlatina,  and  3  of  typhus  remained  under  treatment 
in  hospital  on  Saturday. 

Deaths  from  diseases  of  the  respiratory  system,  which  had  risen  from 
46  for  the  week  ended  April  23,  to  86  for  the  following  week,  fell  again 
to  46,  but  this  number  is  4  over  the  average  for  the  corresponding  week 
of  the  last  ten  years,  The  46  deaths  comprise  23  from  bronchitis,  18 
from  pneumonia  or  inflammation  of  the  lungs,  and  1  from  pleurisy. 


Sanitary  and  Meteorological  Notes.  85 

In  the  week  ending  Saturday,  May  14,  the  mortality  in  thirty-three 
large  English  towns,  including  London  (in  which  the  rate  was  19'5), 
was  equal  to  an  average  annual  death-rate  of  20*4  per  1,000  persons 
living.  The  average  rate  for  eight  principal  towns  of  Scotland  was  22*8 
per  1,000.  Id  Glasgow  the  rate  was  27*6,  and  in  Edinburgh  it  was 
21-0. 

The  average  annual  death-rate  represented  by  the  deaths  registered  in 
the  sixteen  principal  town  districts  of  Ireland  was  27*7  per  1,000  of  the 
Jinrevised  population  based  ou  the  Census  of  1891. 

The  deaths  from  the  principal  zymotic  diseases  in  the  sixteen  districts 
were  equal  to  an  annual  rate  of  3"5  per  1,000,  the  rates  varying  from  0*0 
in  ten  of  the  districts  to  5*2  in  Sligo— the  7  deaths  from  all  causes 
registered  in  that  district  comprising  1  from  simple  continued  fever. 
Among  the  139  deaths  from  all  causes  registered  in  Belfast  are  14  from 
measles  (a  decline  of  7  as  compared  with  the  number  for  the  preceding 
week),  3  from  whooping-cough,  2  from  diphtheria,  1  from  simple  con- 
tinupd  fever,  3  from  enteric  fever,  and  2  from  diarrhoea.  The  32  deaths 
in  Cork  comprise  2  from  measles. 

In  the  Dublin  Registration  District  the  registered  births  amounted  to 
220 — 113  boys  and  107  girls;  and  the  registered  deaths  to  208 — 92 
males  and  1 16  females. 

The  deaths,  which  are  18  over  the  average  number  for  the  correspond- 
ing week  of  the  last  ten  years,  represent  an  annual  rate  of  mortality  of  31  '0 
in  every  1,000  of  the  population.  Omitting  the  deaths  (numbering  9)  of 
persons  admitted  into  public  institutions  from  localities  outside  the  district, 
the  rate  was  29*7  per  1,000.  During  the  first  nineteen  weeks  of  the 
current  year  the  death-rate  averaged  37*2,  and  was  5*7  over  the  mean 
rate  in  the  corresponding  period  of  the  ten  years  1882-1891. 

The  number  of  d«.aths  from  zymotic  diseases  registered  is  38,  being  19 
in  excess  of  the  average  for  the  corresponding  week  of  the  last  ten  years, 
but  15  under  the  numlser  for  the  week  ended  May  7.  The  38  deaths 
comprise  24  from  measles  (being  16  under  the  number  from  that  cause 
in  the  preceding  week),  2  from  influenza  and  its  complications,  3  from 
whooping-cough,  1  from  enteric  fever,  and  1  from  diarrhoea. 

Fifty-eight  cases  of  measles  were  admitted  to  hospital,  being  one  over 
the  admissions  for  the  preceding  week,  but  28  below  the  admissions  for 
the  week  ended  April  30.  Sixty-six  measles  patients  were  discharged,  6 
died,  and  160  remained  under  treatment  on  Saturday,  being  14  under 
tiie  number  in  hospital  at  the  close  of  the  preceding  week. 

The  hospital  admissions  for  the  week  include,  also,  3  cases  of  enteric 
fever,  4  of  scarlatina  and  1  of  typi;us.  Fifteen  cases  of  enteric  fever,  14 
of  scarlatina,  and  4  of  typhus  remained  under  treatment  in  hospital  on 
Saturday. 

Deaths  from  diseases  of  the  respiratoiy  system  amount  to  48,  being  2 


86  Sanitary  and  Metewological  Noten. 

over  the  number  for  the  preceding  week,  and  11  above  the  average  for 
the  19th  week  of  the  last  ten  years.  The  48  deaths  consist  of  25  fioin 
bronchitis^  20  from  pneumonia  or  inflammation  of  the  lungs,  2  from 
pleurisy,  and  1  from  croup. 


In  the  week  ending  Saturday,  May  21,  the  mortality  in  thirty-three 
large  English  towns,  including  London  (in  which  the  rate  was  1&*4), 
was  equal  to  an  average  annual  death-rate  of  19-3  per  1,000  persons 
living.  The  average  rate  for  eight  principal  towns  of  Scotland  was  21*5 
per  1,000.    In  Glasgow  the  rate  was  26-8,  and  in  Edinburgh  it  was  13-9. 

The  average  annual  death-rate  in  the  sixteen  principal  town  districts 
of  Ireland  was  27*4  per  1,000  of  the  population  (unrevised)  according  to 
the  recent  Census. 

The  deaths  from  the  principal  zymotic  diseases  registered  in  the  sixteen 
districts  were  equal  to  an  annual  rate  of  4*3  per  1,000,  the  rates  varying 
from  O'O  in  eight  of  the  districts  to  4'9  in  Belfast — the  116  deaths  from 
all  causes  registered  in  that  district  comprising  13  from  measles  (a 
decrease  of  1  as  compared  with  the  number  for  the  preceding  week),  1 
from  scarlatina,  2  from  whooping-cough,  1  from  simple  continued  fever, 
5  from  enteric  fever,  and  2  from  diarrhoea.  Among  the  40  deaths  frona 
all  causes  registered  in  Cork  are  4  from  measles  and  1  from  enteric  fever. 
The  11  deaths  in  Limerick  comprise  1  from  typiius  and  I  from  whoopitig- 
cough.    The  10  deaths  in  Londonderry  comprise  2  from  whooping-cough. 

In  the  Dublin  Registration  District  the  registered  births  amounted  to 
181 — 100  boys  and  81  girls;  and  the  registered  deaths  to  232 — 10^ 
males  and  123  females. 

The  deaths,  which  are  58  over  the  average  number  for  the  correspond- 
ing week  of  the  last  ten  years,  represent  an  annual  rate  of  mortality  of 
34-6  in  every  1 ,000  of  the  population.  Omitting  the  deaths  (numbering  9) 
of  persons  admitted  into  public  institutions  from  localities  outside  the 
district,  the  rate  was  33*3  per  1,000.  During  the  first  twenty  weeks  of 
the  current  year  the  death-rate  averaged  37' 1,  and  was  5*9  over  the 
mean  rate  in  the  corresponding  period  of  the  ten  years  1882-1891. 

Forty-four  deaths  from  zymotic  diseases  were  registered,  being  23  in 
excess  of  the  average  for  the  corresponding  week  of  the  last  ten  years, 
and  6  over  the  number  for  the  week  ended  May  14.  The  44  dealiis 
comprise  28  from  measles  (being  4  over  the  number  from  that  cause  in 
the  preceding  week),  1  from  typhus,  4  from  influenza  and  its  complica- 
tions, 3  from  whooping-cough,.  4  from  diarrhoea,  and  1  from  dysentery. 

Seventy-three  cases  of  measles  were  admitted  to  hospital,  being  15 
over  the  admissions  for  the  preceding  week,  and  16  over  the  number  for 
the  week  ended  May  7.  Sixty-seven  measles  patients  were  discharged, 
3  died,  and  163  remained  under  treatment  on  Saturday,  being  3  over  the 
number  in  hospital  at  the  close  of  the  preceding  week. 


Sanitary  and  Meteorological  Notes.  ^7 

The  hospital  admissions  for  the  week  include,  also,  3  cases  of  enteric 
fever,  3  of  scarlatina,  and  one  of  typhus.  Eighteen  cases  of  enteric 
fever,  17  of  scarlatina,  and  4  of  typhus  remained  under  treatment  in 
hospital  on  Saturday. 

Deaths  from  diseases  of  the  respiratory  system  amount  to  45,  being 
12  in  excess  of  the  average  for  the  20th  week  of  the  last  ten  years,  but 
3  below  the  number  for  the  preceding  week.  The  45  deaths  comprise 
25  from  bronchitis  and  15  from  pneumonia  or  inflammation  of  the  lungs. 


Meteorology. 


Abstract  of  Observations  made  in  the  Ciiy  of  Dublin^  Lat.  53°  20'  iV., 
Long.  6°  15'  W.,  for  the  Month  of  May,  1892. 

Mean  Height  of  Barometer,  _  .  .  29'944  inches. 

Maximal  Height  of  Barometer  (on  12th,  at  9  a.m.).  -    30'38i     „ 

Minimal  Height  of  Barometer  (on  28th,  at  9  p.m.)  -  29-474     „ 

Mean  Dry-bulb  Temperature,  -  -  -  52'9°. 

Mean  Wet-bulb  Temperature,  .  _  -  49"3°. 

Mean  Dew-point  Temperature,         ...  45'7°. 
Mean  Elastic  Force  (Tension)  of  Aqueous  Vapour,  -         '310  inch. 

Mean  Humidity,     -----  77*0  per  cent. 

Highest  Temperature  in  Shade  (on  25th)     -  -  69*5°. 

Lowest  Temperature  in  Shade  (on  5th),       -  -  37'9°. 

IjO west  Temperature  on  Grass  (Radiation)  (on  5th),  31  •5°. 

Mean  Amount  of  Cloud,      -  -  -  .  59*9  per  cent. 

Rainfall  (on  19  days),         -  -  -  -  4'177  inches. 

Greatest  Daily  Rainfall  (on  28th),  -  -  -  2*056  inches 

General  Directions  of  Wind,  -  -  -  W.S.W.,E.N.E 

Remarks. 

A  generally  favourable  though  changeable  month.  At  first  dry,  cold, 
and  bright;  afterwards  warm  but  unsettled,  with  frequent  showers  or 
even  heavy  rains,  and  strong  southwesterly  winds.  After  the  12th,  rain 
fell  almost  daily.  On  the  28th  there  was  an  extraordinary  downpour, 
lasting  6  hours,  within  which  space  of  time  1*9  inches  of  rain  fell 
in  Dublin,  or  at  the  rate  of  7*6  inches  in  24  hours.  The  total  rainfall  of 
the  28th  was  2*056  inches,  or  nearly  one-half  that  of  the  whole  month. 

In  Dublin  the  arithmetical  mean  temperature  (53*8°)  was  decidedly 
above  the  average  (52*0°);  the  mean  dry  bulb  readings  at  9  a.m.  and 
9  p.m.  were  52*9°.  In  the  twenty-seven  years  ending  with  1891,  May 
was  coldest  in  1869  (M.  T.  z=  48*2°),  in  1885  (M.  T.  =  48*7°),  and  in 
1879  (the  "cold  year")  (M.  T.  =  488°).  It  was  warmest  in  1868  (the 
"  warm  year  ")  (M.  T.  =  55*8°,  and  1875  (M.  T.  =  54*9°).     In  1886  the 


88  Sanitary  and  Meteorological  Notes. 

M.  T.  was  50-5°,  in  1887  it  was  51-8°,  in  1888  it  was  52-5°,  in  1889  it 
was  54-6°,  in  1890  it  was  53-2°,  and  in  1891  it  was  only  49-6^ 

The  mean  height  of  the  barometer  was  29*944  inches,  or  0*045  inch 
below  the  corrected  average  value  for  May — namely,  29*989  inches.  The 
mercury  rose  to  30*381  inches  at  9  a.m.  of  the  12th,  and  fell  to  29*474 
inches  at  9  p.m.  of  the  28th.  The  observed  range  of  atmospherical 
pressure  was,  therefore,  0*907  inch — that  is,  a  little  more  than  nine- 
tenths  of  an  inch. 

The  mean  temperature  deduced  from  daily  readings  of  the  dry  bulb 
thermometer  at  9  a.m.  and  9  p.m.  was  52*9°,  or  7*6°  above  the  value  for 
April,  1892.  Using  the  formula.  Mean  Temp.  ^  Min.  +  {max. — min.  x 
•47),  the  value  was  53*3°,  or  1*7°  above  the  average  mean  temperature 
for  May,  calculated  in  the  same  way,  in  the  twenty-five  years,  1865-89, 
inclusive  (51*6°).  The  arithmetical  mean  of  the  maximal  and  minimal 
readings  was  53*8°,  compared  with  a  twenty-five  years'  average  of  52 "0°. 
On  the  25th  the  thermometer  in  the  screen  rose  to  69*5° — wind,  W.S.W. ; 
on  the  5th  the  temperature  fell  to  37*9° — wind,  N.E.  The  minimum  on 
the  grass  was  31*5°  also  on  the  5th. 

The  rainfall  amounted  to  4*177  inches,  distributed  over  19  days.  The 
average  rainfall  for  May  in  the  twenty-five  years,  1865-89,  inclusive,  was 
2*030  inches,  and  the  average  number  of  rainy  days  was  15*4.  The 
rainfall  and  the  rainy  days,  therefore,  were  much  above  the  average. 
In  1886  the  rainfall  in  May  was  very  large — 5*472  inches  on  21  days; 
in  1869  also  5*414  inches  fell  on  19  days.  On  the  other  hand,  in  1871, 
only  '378  of  an  inch  was  measured  on  9  days;  in  1876  only  '798  of  an 
inch  fell  on  6  days ;  in  1887  only  *882  of  an  inch  fell  on  10  days ;  and  in 
1888  only  -978  of  an  inch  on  11  days.  In  1890,  2*438  inches  fell  on  17 
days.  In  1891  May  was  the  first  month  in  which  the  rainfall  exceeded 
the  average.     It  amounted  to  2*792  inches  on  17  days. 

Solar  halos  were  seen  on  the  17th,  24th,  and  27th.  High  winds  were 
noted  on  as  many  as  11  days,  attaining  the  force  of  a  gale,  however,  oo 
only  one  occasion — namely,  the  16th.  Hail  fell  on  the  16th.  No  thunder 
or  lightning  occurred  in  Dublin. 

During  the  month  the  thermometer  in  the  screen  did  not  fall  below 
32°,  but  on  four  nights  a  temperature  of  32°  or  less  was  recorded  on  the 
grass.  The  mean  minimal  temperature  on  the  grass  was  41*3°,  compared 
with  37*7°  in  May,  1891,  42*2°  in  1890,  424°  in  1889,  37*5°  in  1888, 
and  37*9°  in  1887. 

During  the  week  ended  Saturday,  the  7th,  while  an  abundant  rainfall 
was  experienced  over  the  greater  part  of  the  British  Islands  between 
Monday  and  Wednesday,  there  was  little  spring  growth  owing  to  a  per- 
sistence of  northeasterly  winds  and  low  temperatures,  both  by  day  and 
by  night.  At  the  beginning  and  close  of  the  week  gradients  for  westerly 
(8.  to  W.  and  N.W.)  winds  existed  and  the  weather  was  comparatively 


Sanitarij  and  Meteorological  Notes.  89 

mild ;  but  from  Monday  to  Friday  inclusive  the  highest  atmospherical 
pressure  was  found  to  the  N.  and  N.W.,  while  a  series  of  depressions 
alternately  formed  and  dispersed  along  a  trough  of  low  pressure  extend- 
ing northeastwards  from  the  Bay  of  Biscay  to  the  Baltic.  Hence,  the 
cold  northeast  winds  already  referred  to.  On  Sunday,  the  1st,  the  weather 
was  unsettled  in  Ireland  and  a  heavy  fall  of  rain  occurred  in  the  S. 
(0-95  inch  at  Roche's  Point).  On  Monday  night  rain  set  in  with  N.E. 
winds  in  Dublin,  0*476  inch  falling  between  9  p.m.  of  this  day  and 
Wednesday  morning.  There  was  alternate  cloud  and  sunshine  from  this 
time  to  the  end  of  the  week,  but  no  rain  fell  in  Dublin.  The  mean 
height  of  the  barometer  was  30'034  inches,  pressure  varying  between 
29"784  inches  at  9  p.m.  of  Sunday  (wind,  S.E.)  and  30-253  inches  at 
9  a.m.  of  Friday  (wind,  E.).  The  corrected  mean  temperature  was 
46"7°.  On  Saturday  the  screened  thermometers  rose  to  58*7°,  having 
fallen  to  37  9°  on  Thursday.  The  mean  dry  bulb  reading  at  9  a.m.  and 
9  p.m.  was  46*9°.  Rain  fell  on  two  days  to  the  total  amount  of  -476 
inch,  of  which  '316  inch  was  measured  on  Monday.  The  prevailing 
wind  was  N.E.  A  sharp  frost  occurred  on  Friday  night  over  S.E. 
England,  the  thermometer  falling  in  the  screen  to  26°  at  Cambridge  and 
to  29°  even  in  London. 

Taken  as  a  whole,  the  weather  of  the  week  ended  Saturday,  the  14th, 
was  favourable.  Until  Thursday,  it  was  settled  and  quiet — warm  sunny 
days  alternating  with  sharp,  hazy  nights.  On  Thursday  the  sky  became 
overcast  with  cirro-stratus  and  cumulus  in  Ireland  and  the  atmosphere 
grew  close  and  oppressive.  In  the  afternoon  a  copious  fall  of  warm  rain 
set  in  all  over  this  country,  literally  changing  the  face  of  nature  through 
the  impetus  it  gave  to  vegetation.  Friday  was  a  breezy,  dull,  rainy  day, 
while  Saturday  proved  bright  with  fresh  to  strong  westerly  winds.  The 
rainfall  of  Thursday  and  Friday  was  general  throughout  Ireland ;  in 
Scotland  rain  also  fell  generally  but  in  smaller  quantities  ;  but  in  England 
the  weather  remained  fair  and  dry  until  Friday,  when  the  showers  became 
tolerably  general  except  in  the  extreme  S.W.  of  that  country.  In  Dublin 
the  mean  height  of  the  barometer  was  30'186  inches,  pressure  ranging 
between  30*381  inches  at  9  a.m.  of  Thursday  (wind,  E.)  and  30002  inches 
at  9  p.m.  of  Saturday  (wind,  W.).  The  corrected  mean  temperature  was 
53*7''.  The  mean  dry  bulb  temperature  at  9  a.m.  and  9  p.m.  was  also 
53*7°.  The  thermometer  in  the  shade  rose  to  68*9°  on  Thursday  and  fell 
to  39*2°  on  Monday.  The  rainfall  amounted  to  •618  inch  on  three  days, 
•479  inch  being  entered  to  Thursday.  An  almost  total  eclipse  of  the  moon 
f  953  out  of  1,000  parts  being  eclipsed)  was  well  seen  on  Wednesday  night. 
Easterly  winds  prevailed  until  Thursday.  Then  the  winds  became  S.W. 
to  W. 

All  through  the  week  ended  Saturday,  the  21st,  the  weather — in  Ireland 
especially — remained  in  a  very  chaiigeal)le,  showery,  rough  and  cool 


90  Sanitary  and  Meteorological  Notes. 

condition.  In  the  south  of  England  it  was  finer  and  drier,  while  the 
northern  part  of  that  country  and  Scotland  also  experienced  very  variable 
weather.  This  state  of  things  was  brought  about  by  the  passage  east- 
wards across  our  northern  districts  of  a  succession  of  depressions,  of  no 
great  depth  indeed,  whereas  an  area  of  high  pressure  hung  over  the  Bay 
of  Biscay  and  France.  Hence  strong,  squally  westerly  (S.W.  to  N.W.) 
winds  and  frequent  showers  prevailed,  Ireland  coming  in  for  the  brunt  of 
the  bad  weather  as  it  swept  in  from  the  Atlantic.  In  Dublin  rain  was 
measured  on  six  out  of  the  seven  days,  and  the  showers  were  particularly 
heavy  on  Monday,  Wednesday,  and  Thursday.  A  brief  spell  of  fair 
weather  set  in  on  Friday  afternoon,  but  the  showers  were  renewed  on 
Saturday  afternoon  after  a  very  sharp  night.  The  weather  was  highly 
favourable  from  an  agricultural  point  of  view.  In  Dublin  the  mean 
height  of  the  barometer  was  29*900  inches,  pressure  ranging  between 
29-644  inches  at  9  a.m.  of  Monday  (wind  W.,  blowing  a  moderate  gale) 
and  30-080  inches  at  9  p.m.  of  Friday  (wind,  W.N.W.).  The  corrected 
mean  temperature  was  52*9°.  The  mean  dry  bulb  temperature  at  9  a.m. 
and  9  p.m.  was  52-3°.  The  screened  thermometers  rose  to  61'8°  on 
Wednesday  and  fell  to  40*4°  on  Saturday.  The  rainfall  was  '579  inch, 
of  which  "228  inch  fell  on  Thursday.  Hail  fell  on  Monday,  when  also 
there  was  a  moderate  westerly  gale.  The  prevailing  winds  were 
westerly. 

During  the  week  ended  Saturday,  the  28th,  except  on  Sunday  and 
Monday,  when  the  area  of  least  atmosplierical  pressure  was  found  over 
Sweden  and  the  Baltic,  the  barometer  was  lowest  over  the  Bay  of  Biscay, 
the  British  Islands,  and  the  Atlantic  Ocean.  Hence  gradients  for 
southerly  winds  prevailed  and  the  weather  was  kept  in  a  changeable 
showery  state,  particularly  in  Ireland  and  Scotland.  The  southerly 
winds  brought  a  great  rise  of  temperature  to  France,  Germany,  and 
England,  where  the  weather  remained  chiefly  fine  and  dry  until  Wednes- 
day, when  a  succession  of  thunderstorms  began.  On  this  day,  the 
thermometer  rose  to  90°  in  Paris  and  to  91°  at  Biarritz— the  highest 
readings  in  England  were  80°  at  Cambridge,  78°  in  London  and  at  the 
North  Foreland.  On  Friday  95°  was  reached  in  Berlin  and  92°  at 
Belfort,  while  76°  in  London  and  at  the  North  Foreland  and  75°  at  Cam- 
bridge were  the  highest  British  readings.  Veiy  severe  thunderstorms 
passed  over  England  during  this  period,  and  local  heavy  falls  of  rain  and 
hail  occurred.  On  Saturday  there  was  an  extraordinary  downpour  of 
rain  in  Dublin — 1-902  inches  falling  in  six  hours  between  9  15  a.m.  and 
3  15  p.m.  The  mean  height  of  the  barometer  was  29731  inches,  pressure 
ranging  from  29902  inches,  at  9  a.m.  of  Sunday  (wind,  S.E.)  to  29-474 
inches  at  9  p.m.  of  Saturday  (wind,  variable).  The  corrected  mean 
temperature  was  57*3°,  while  the  mean  dry  bulb  reading  at  9  a.m.  and 
9  p.m.  was   56-8°.     The  thermometers  in  the  screen  fell  to  46*0°  on 


Periscape.  91 

Funday  and  rose  to  69-5®  on  Wednesday.  The  wind  was  first  soutlierlv, 
then  light  easterly.  The  rainfall  was  2-378  inches,  on  six  days,  2-O.Ofj 
inches  beinj?  re^iistered  on  Saturday.  No  such  daily  measurement  has 
been  recorded  in  Dublin  since  October  27,  1880,  when  2-736  inches  of 
rain  fell.  The  present  is  only  the  third  occasion  within  the  past  twenty- 
seven  years  on  which  the  rainfall  exceeded  2  inches  within  24  hours  in 
Dublin. 

The  last  three  days  of  the  month  were  changeable,  with  fresh  or  strong 
southerly  to  south-westerly  winds,  cloudy  skies,  and  passing  showers  at 
times. 

The  rainfall  in  Dublin  during  the  five  months  ending  May  31st  has 
amounted  to  10-099  inches  on  80  days  compared  with  only  5*995  inches 
on  63  days  during  the  same  period  in  1891,  11'483  inches  on  76  days 
in  1890,  10-476  inches  on  91  days  in  1889,  9-068  inches  on  69  days 
in  1888,  6-489  inches  on  62  days  in  1887,  and  a  25  years'  average  of 
10-496  inches  on  81*6  days. 

At  Knockdolian,  Greystones,  Co.  Wicklow,  the  rainfall  in  May.  1892, 
was  4*695  inches,  distributed  over  17  days.  Of  this  quantity  1-180  inches 
fell  on  the  12th,  -460  inch  on  the  24th.  and  1-560  inches  on  the  28th. 
The  total  fall  since  January  1st,  1892,  equals  9548  inches  on  67  days. 


PERISCOPE. 

EHRLICh'S    test    of    urine    I>f    TYPHOID    FEVER. 

Dr.  Arthur  R.  Edwards,  after  making  600  analyses  of  urine,  and 
applying  Ehrlich's  test,  comes  to  the  following  conclusions  {Medic d 
News  of  Philadelphia,  12th  March,  1892): — "  1.  The  reaction  is  inde- 
pendent of  any  sir.gle  disease  or  any  group  of  diseases.  2.  It  is  fre- 
quently found  in  urine  containing  albumen,  peptone,  biliary  substances, 
sugar,  aromatics,  and  possibly  leucomaines  or  ptomaines.  3.  We  have 
failed  to  obtain  more  constant  results  with  the  absolute  alcohol  than 
without  its  use.  4.  Ehrlich's  test  is  not  always  present  in  typhoid,  even 
at  the  acme  of  the  disease ;  it  was  absent  in  1^  per  cent,  of  our  cases. 
The  reaction,  therefore,  is  at  best  only  a  presumptive,  and  not  a  positive, 
evidence  of  typhoid.  Its  value  is  on  a  par  with  that  of  gurgling  and 
tenderness  in  the  right  inguinal  region  and  inferior  to  the  temperature, 
mseolae,  and  splenic  tumour.  5.  Together  with  more  reliable  signs  and 
symptoms,  as  temperature,  enlarged  spleen,  &c.,  it  may  contribute  to  a 
diagnosis  of  typhoid,  and  conversely,  when  absent,  in  98^  cases  out  of 
lAO,  the  disease  is  other  than  typhoid.  6.  It  is  found  in  many  otht^r 
diseases,  some  of  which,  in  certain  clinical  features,  may  simuhtte  tvphoid — • 
e.g.^  septicaemia,  uraemia,   tuberculosis  in  its  varied  aspects,  intestinal, 


92  Perncope. 

peritoneal,  miliary,  &c.,  as  well  as  enteritis,  malaria,  and  pneumonia. 
In  differential  diagnosis,  therefore,  when  other  distinctive  symptoms  are 
lacking,  the  sulphanilic  acid  test  is  untrustworthy.  It  fails  when  most 
keenly  wanted,  and  may  be  absent  in  otherwise  typical  typhoid  fever. 
7.  If  much  reliance  is  placed  in  the  test,  a  typhoid  relapse  may  be  con- 
founded with  complications.  We  have  observed,  as  complications  and 
early  sequelse  yielding  the  reaction,  acute  nephritis,  lobar  pneumonia, 
pulmonary  tuberculosis,  pleurisy,  &c.,  and  would  have  been  at  a  loss  as 
to  the  cause  if  confidence  had  been  reposed  in  the  test.  8.  Inasmuch  as 
it  occurs  typically  in  many  diseases  in  which  the  causes  and  elaborated 
products  differ,  and  since  the  various  compounds  with  which  the  diazo- 
benzene-sulphonic  acid  unites  are  as  yet  unknown,  the  reaction  cannot 
commend  itself  to  tlie  scientific  chemist,  however  it  may  be  regarded 
clinically." 

TUBERCULIN    IN    THE   DIAGNOSIS    OF    TUBERCULOSIS    IN    CATTLE. 

Leonard  Pearson,  B.S.,  V.M.D.,  of  the  Veterinary  Department,  Uni- 
versity of  Pennsylvania,  records  {Medical  News  of  Philadelphia,  9th  April, 
1892)  some  cases  in  which  he  injected  tuberculin  into  cows  in  order  to 
test  whether  they  suffered  from  tuberculosis.  He  writes : — "  So  far  as 
my  experience  goes,  tuberculin  seems  to  be  a  safe  agent  for  the  diagnosis 
of  tuberculosis  in  cattle." 

percentage    of    deaths    IN    chloroform    ADMINISTRATION. 

Dr.  B.  W.  Richardson  (Asclepiad,  33)  analyses  the  mortality  fi-om  chloro- 
form, and  concludes  that  the  deaths  may  be  as  one  in  3,500  inhalations, 
but  that  probably  one  death  in  2,000  to  2,500  administrations  is  nearer 
the  truth,  yet  even  at  the  lowest  rate  we  employ  no  other  narcotic  that 
approaches  chloroform  for  danger. 

THE    influence    OF    HEREDITY. 

Dr.  Woods  Hutchinson,  writing  on  the  influence  of  heredity  (Medical 
News,  Philadelphia,  Feb.  13th,  1892),  ends  thus: — "To  sum  up  roughly, 
we  find  a  tainted  pedigree — 

Among  57,000  cases  of  insanity,  in  lO'l  per  cent. 

„         30,000         „      carcinoma,  „   10-5        „ 

„  22,000  „  tuberculosis,  „  37-3  „ 
These  estimates  are,  of  course,  made  on  far  too  narrow  a  basis  to  be 
regarded  as  in  any  way  conclusive,  and  their  reliability  for  positive  pur- 
poses is  open  to  serious  question  in  many  particulars,  but  I  think  they  at 
least  justify  us  in  demanding,  in  answer  to  the  charge  that  heredity  is, 
in  any  sense,  a  prominent  or  active  factor  in  the  production  of  disease, 
the  Scotch  verdict  of  '  Not  proven.'     On  the  other  hand,  all  the  remedial 


Periscope.  93 

power  of  Nature,  individual  and  racial,  all  the  vinrour  that  defies  attack, 
all  the  priceless  immunity  from  disease,  all  the  exquisite  harmony  with 
environment  that  surrounds  us  on  every  hand,  are  the  direct  results  and 
illustrations  of  the  law  of  heredity.  Its  beneficent  effects  are  innumerable 
and  unquestionable;  its  injurious  effects  few  and  doubtful." 

UNIQUE   CASE   OF    INTUSSUSCEPTION. 

Dr.  Morris  B.  Miller  reports  {Medical  News,  Philadelphia,  December 
12th,  1891)  a  unique  case  of  intussusception.  The  whole  of  the  iiivagi- 
nated  portion  of  the  bowel  (the  pieces  measuring  in  the  aggregate  fifty- 
four  inches)  was  discharged  a  week  before  death,  which  did  not  occur  for 
over  a  month  after  the  involution  took  place. 

THE    HARVARD    MEDICAL    SCHOOL    ASSOCIATION. 

This  Association  has  issued  an  interesting  and  valuable  list  of  its 
members,  which  it  will  be  glad  to  send  to  graduates  of  the  Medical 
Department  of  Harvard  University,  in  whatever  part  of  the  world  they 
may  be.  The  Association  was  formed  about  one  year  ago,  and  all 
graduates  of  the  School  are  eligible  to  membership.  The  object  is  to 
imite  all  alumni  and  to  advance  the  interests  of  the  School  and  of 
medicine.  The  entrance  fee  and  the  annual  assessment  are  merely 
nominal. 

MEDICO-CHIRURGICAL   SOCIETY,    GLASGOW. 

At  the  Annual  General  Meeting  of  the  Society  the  following  gentlemen 
were  elected  office-bearers  for  Session  1892-93  : — President:  Dr.  Joseph 
Coats.  Section  of  Medicine — Vice-President :  Dr.  Middleton  ;  Council- 
lors :  Dr.  Alex.  Miller  and  Dr.  Auld ;  Secretary :  Dr.  C.  0.  Hawthorne. 
Section  of  Surgery — Vice-President :  Dr.  W.  J.  Fleming ;  Councillors  : 
Dr.  Macartney  and  Dr.  Dalziel ;  Secretary ;  Dr.  John  Barlow.  Section 
of  Pathology — Vice-President :  Dr.  J.  L.  Steven  ;  Councillors :  Dr. 
Charles  Workman  and  Dr.  John  Brown  ;  Secretary :  Dr.  R.  M.  Buchanan. 
Section  of  Obstetrics — Vice-President :  Dr.  Samuel  Sloan  ;  Councillors  : 
Dr.  M.  Cameron  and  Dr.  Lapraik ;  Secretary :  Dr.  Lawrence  Oliphant. 
Treasurer :  Mr.  Henry  E.  Clark.    General  Secretary :  Dr.  Walker  Downie. 

POPULAR    PRESCRIPTIONS. 

The  Medical  Record  assures  us  that  a  well-known  Philadelphia  pharmacist 
has  recently  received  the  following  written  orders  for  medicine  : — A  dose 
of  castor-oil  for  a  child  aged  fifteen.  Be  sure  and  send  enough  to  work 
her  good.  One  dozen  two-ounce  quinine  pills  ;  one  bottle  honeatta 
water  ;  a  boo  gee  ;  one  box  of  Brandteth's  pills,  sugar  quoted.  Please 
send  enough  appecac  to  throw  up  a  four  months  old  baby;  two  five-grain 
blue  mask  pills ;  ten  cents  worth  partisapated  chalk. 


n 


emortam. 


WILLIAM  COLLES,  M.D.  UNIV.  DUBL..  F.R.C.S.I. ; 

Surgeon-in-Ordinary  to  Her  Majesty  the  Queen  in  Ireland  ; 

Consulting  Surgeon  to  Steeveus'  Hospital, 

And  to  the  Rotunda  Lying-in  Hospital,  Dublin. 


Notwithstanding  that  William  Colles  had  long  passed  life's 
mile-stone  of  four-score  years,  the  tidings  of  his  sudden  death  on 
Saturday,  June  18,  1892,  came  to  his  many  friends  as  a  painful 
surprise.  Only  a  few  days  before  his  death,  his  well-known  figure 
had  been  seen  at  the  University  Club  and  in  the  streets  of  the 
city.  The  very  end  was  startling  in  its  suddenness.  He  had 
expressed  himself  as  feeling  so  much  better  that  he  was  sure  his 
physician  would  at  his  expected  visit  allow  him  to  sit  up — a  deep 
sigh  or  gasp,  and  in  a  very  few  moments  all  was  over ! 

So  died  one  of  the  ablest,  as  he  was  one  of  the  most  modest  and 
retiring,  of  our  Irish  surgeons — the  worthy  inheritor  of  his  father's 
name — with  "  honour,  love,  obedience,  troops  of  friends." 

William  Colles  was  born  on  July  2,  1809,  at  No.  13  St. 
Stephen's  Green,  Dublin.  His  father  was  the  celebrated  surgeon, 
Abraham  Colles,  whose  description  of  the  fracture  of  the  lower 
end  of  the  radius  has  given  to  this  injury  the  name  of  ''  CoUes's 
fracture."  His  mother  was  Sophia,  daughter  of  the  Reverend 
Jonathan  Cope,  Rector  of  Ahascragh,  Co.  Galway.  Educated  at 
an  Irish  school,  young  Colles  was  apprenticed  to  his  father  on 
April  11,  1826,  and  entered  upon  his  professional  studies  in  the 
School  of  Surgery  of  the  Royal  College  of  Surgeons  in  Ireland  and 
at  Steevens'  Hospital.  About  the  same  time  be  entered  Trinity 
College,  Dublin,  where  he  graduated  in  Arts  in  the  year  1831. 
Op  the  9th  of  July  in  the  same  year  he  obtained  the  Letters 
Testimonial  of  the  Royal  College  of  Surgeons,  of  which  he  was 
elected  a  Member  on  May  1,  1837.  After  obtaining  his  surgical 
qualification,  Colles  spent  some  time  in  the  hospitals  of  Vienna, 
Berlin,  and  Gottingen.  In  1834  he  was  elected  House  Surgeon  to 
Steevens'  Hospital,  a  post  which  he  held  for  the  usual  term  of 
seven  years,  when  he  became  Visiting  Surgeon  to  the  Hospital — 


$tt  fttemortam.  i)o 


an  appointment  which  he  filled  for  well-nigh  half  a  century.  So 
long  as  the  Medical  School  attached  to  the  Hospital  was  in 
existence  he  was  one  of  the  lecturers  on  surgery  in  it. 

In  1841  CoLLES  graduated  in  medicine  in  the  University  of 
Dublin,  but  it  was  not  until  1865  that  he  proceeded  to  the  higher 
degree  of  Doctor  of  Medicine.  In  1844  he  became  a  Fellow  of 
the  Royal  College  of  Surgeons  in  Ireland. 

Although  modest  and  retiring  in  disposition  to  a  fault,  Colles 
did  not  long  remain  without  tokens  of  public  and  professional 
esteem.  In  connection  with  the  Royal  College  of  Surgeons  in 
Ireland  he  held  for  many  years  the  honorary  offices  of  Librarian 
and  Secretary.  In  1863-64  he  was  President  of  his  College.  He 
was  elected  Consulting  Surgeon  to  the  Rotunda  Lying-in  Hospital, 
and  to  Sir  Patrick  Dun's  Hospital.  But  still  higher  honours  fell 
to  his  lot,  unasked  for  and  unsought.  On  the  death  of  Mr.  Robert 
Adams,  in  1875,  he  became  Regius  Professor  of  Surgery  in  the 
University  of  Dublin,  while  the  Queen  marked  her  appreciation  of 
his  professional  standing  and  sterling  qualities  as  a  Surgeon  by 
appointing  him  one  of  her  Surgeons-in-Ordinary  in  Ireland. 

Mr.  Colles  married,  in  1850,  Pamella  Hatchell,  daughter  of  Mr. 
Cadwallader  Waddy,  of  the  County  Wexford,  which  county  at  one 
time  that  gentleman  represented  in  Parliament.  Three  children  of 
this  marriage  survive — JMr.  Abraham  Colles,  who  inherits  his  grand- 
father's name  and  practises  at  the  Irish  bar;  and  two  married 
daughters.  To  his  family,  it  has  been  well  said,  William  Colles 
has  left  "  the  priceless  heritage  of  an  honoured  name." 

The  subject  of  this  memoir  was  a  man  of  few  words,  but  he 
contributed  to  medical  literature  many  papers  of  sterling  merit. 
The  following  is  a  full  list  of  his  contributions  to  the  pages  of  this 
Journal  between  the  years  1 845  and  1 888  : — 

1.  "On  the  Treatment  of  a  Peculiar  Form  of  Disease  of  the 
Prostate  Gland."     First  Series.     Vol.  XXVIL     1845. 

2.  "  Observations  upon  Urinary  Fistula."  Second  Series. 
Vol.  IV.     1847.     Page  57. 

3.  "  Cases  of  Injurious  Effects  following  the  Use  of  Rye  as 
Food."     Vol.  IV.     1847.     Page  243. 

4.  "  Observations  on  Nasal  Polypi."   Vol.  VL    1848.    Page  373. 


96  ftn  fitcmonam* 


5.  "  An  Improved  Method  of  Operating  for  Congenital  Phimosis." 
Vol.  VII.     1849.     Page  250. 

6.  "On  a  Peculiar  Form  of  Gonorrhoea."  Vol.  X.  1850. 
Page  102. 

7.  "  Case  of  Femoral  Aneurism  Cured  by  Pressure."  Vol.  XI. 
1851.     Page  497. 

8.  "  On  Traumatic  Spasms."     Vol.  XIII.     1852.     Page  33. 

9.  "  Selections  from  the  unpublished  Manuscripts  of  the  late 
Abraham  CoUes."  Vol.  XV.  1853.  Page  280.  Vol.  XVI. 
1853.  Pages  55  and  290.  Vol.  XVII.  1854.  Page  82. 
Vol.  XVIII.  1854.  Page  28.  Vol.  XX.  1855.  Page  335. 
Vol.  XXII.     1856.     Page  27.     Vol.  XXIII.     1857.     Page  374. 

10.  "  Report  of  Two  Cases  in  which  Ligature  was  applied  to  the 
Posterior  Auris  Artery."     Vol.  XIX.     1855.     Page  73. 

11.  "Account  of  a  Case  in  which  Death  was  occasioned 
by  a  Fish-bone  penetrating  the  Aorta  through  the  CEsophagus. 
Vol.  XIX.     1855.     Page  325. 

12.  "  On  Aneurismal  Sacs."     Vol.  XXI.     1856.     Page  53. 

13.  "Case  of  Reducible  Inguinal  Hernia — Radical  Cure  per- 
formed according  to  Wood's  Method."  Vol.  XXXIII.  1862. 
Page  243. 

14.  "  Cases  of  Injuries  of  the  Larger  Joints,  with  Remarks." 
Vol.  XLI.     1866.     Page  47. 

15.  "Case of  Trephining  the  Mastoid  Process."  Vol.  L.  1870. 
Page  32. 

16.  "  Dr.  Sayres' Splint  applied  to  Fractured  Neck  of  Femur." 
Vol.  LIII.     1872.     Page  187. 

17.  "The  Treatment  of  Haemorrhoids  by  the  Injection  of  the 
Tincture  of  Perch loride  of  Iron."     Vol.  LVIL     1874.     Page  505. 

18.  "  Case  of  Necrosis  of  Femur,  with  Remarks."  Vol.  LXIV. 
1877.     Page  201. 

19.  "  On  Aneurismal  Sacs."     Vol.  LXIV.     1877.     Page  281. 

20.  "Necrosis  without  Suppuration."  Vol.  LXVI.  1878. 
Page  453. 

21.  "The  Diagnosis  of  Cancer  of  the  Testis."  Vol.  LXXXVL 
1888.     Page  1. 

22.  "The  Influence  of  Position  on  Fractures  of  the  Lower 
Extremities."     Vol.  LXXXVL     1888.     Page  192. 


Misrellaneous  A  dvertisements. 


25 


THE  LANCET, 

A  Journal    of  British   and    Foreign 
Medicine,  Surgery,  Obstetrics, 

Physiology,  Chemistry,  Pharmacology, 
Public  Health,  and  News. 


\_Copy  of  Circular  Letter.] 


London.] 


[Saturday. 


ANALYTICAL  RECOEDS. 


(CAFFYN'S  LIQUOR-CARNIS.) 

"  This  is  evidently  a  meat  extract 
prepared  in  the  cold  and  preserved  by- 
glycerine.  It  is  extremely  rich  in 
nitrogen,  and  the  ash  contains  phos- 
phates in  considerable  quantity.  So 
well  are  the  soluble  albuminoids  of  the 
meat  preserved  that  the  fluid  when 
heated  turns  into  a  semi-solid  jelly. 
It  is  a  really  valuable  nutrient," 


BRAITHWAITE'S  RETROSPECT 
OF  MEDICINE. 

A  Half-yearly  Journal,  containing  a 

Retrospective  View  of  every 

Discovery  and  Practical  Improvement 

in  the  Medical  Science. 

"  Of  all  the  forms  of  prepared  nitro- 
genous food  before  the  profession, 
Caffyn's  Liquor  Camis  (Beef  Juice), 
both  by  its  method  of  manufacture 
and  its  proximate  composition,  appears 
to  us  most  nearly  to  realise  the  ideal 
substitute  for  the  natural  proteid  food 
stuifi." 


Be  THE    PURE    JUICE. 

50  HoLBORN  Viaduct, 
London,  E.G. 
Dear  Sir, 

The  Editors  of  The  Lancet,  Braith- 
waites  Retrospect,  and  the  Court  Circu- 
lar, have  taken  the  trouble  to  collect 
evidence  concerning  a  raw  beef  juice 
preparation  we  put  on  the  market  a 
short  time  ago,  under  the  name  of 
Liquor-Carnis  (Caffyn),  which  is, 
perhaps,  best  described  as  a  nitro- 
genous food,  in  which  the  juice  of 
British  beef  exists  in  precisely  the 
same  condition  as  is  obtained  by  taking 
a  slice  of  beef  steak,  scoring  it  deeply, 
squeezing  out  the  juice,  and  adding 
thereto  a  few  drops  of  Glycerine 
(hydro-carbon). 

Liquor-Carnis  placed  in  a  spoon  or 
test-tube,  and  held  over  a  flame, 
speedily  demonstrates  its  richness  in 
albuminoids,  by  its  sudden  transforma- 
tion into  a  coagulated  albuminous 
mass. 

If  you  wish  for  a  sample  for  trial  in 
your  practice,  will  you  kindly  com- 
municate with  us,  and  your  desires 
shall  have  attention. 

We  are. 
Yours  obediently, 

The  Liquor  Carnis  Co.,  Ltd. 

W.  SaEPPERSON,  Managing  Director. 

0 


ForDiSEASESoftheStOMACH. 

^  Indigestion 

It  is  conclusively  ascertained  that  LACTOPEPTINE 

will  bring  about  the  Digestion  of  Food  in  a  manner 

perfectly    identical    to    that    obtained     under    the 

influence  of  the  natural  gastric  juice. 

mHE  extended  use  and  adoption  of  LACTOPEPTINE 
by  the  MEDICAL  PROFESSION  aflords  indis. 
putable  evidence  that  its  therapeutic  value  has  been 
thoroughly  estabhshed  in  cases  of  Indigestion,  Dys- 
pepsia, Loss  Of  appetite.  Impoverished  Bloog. 
General  Pebilitv.  intestinal  and  Waani.g 
Diseases  of  Children.  Chronic  Diarrhoea,  con- 
stipation, Vomiting  in  Pregnancy,  Headacite, 
Nausea,  and  all  diseases  arising  from  imper- 
fect r^utrition. 

From  "  Retrospect  of  Practical  Medicine  and  Surgery/ 
July,  1877- 
"  A  glance  at  the  formula  of  LACTOPEPTINE  would 
convince  even  the  most  sceptical  of  the  valuable  resul  s  thai 
must  eni^ue  through  its  administration.  It  is  a  combination-ol 
all  the  digestive  agents,  consequently  can  never  be  adminL-terec 
without  giving  the  utmost  satisfaction. 


Extract  from  CertifleaU  of  Composition  and  Proper tiei,  hy 

Professor  ATTFIELD,  Ph.D., 

Profeuor  of  Practical  Chemistry  to  the  Pharmaceutical 
Society  of  Great  Britain. 

LONDON,  May  yrd,  1882. 
I  now  report  that  the  almost  inodorous  and  tasteless  pulverulent 
substance  termed  Lactopeptine  is  a  mixture  of  the  three  chief 
agents  which  enable  ourselves  and  all  animals  to  digest  food. 
That  is  to  say,  Lactopeptine  is  a  skilfully-prepared  combination 
of  meat.converting,  lat-converling,  and  starch.converting 
materials,  acidified  with  those  sn  all  proportions  of  the  acids  thai 
are  always  present  in  the  healthy  stomach  ;  all  being  dissemi- 
nated in  an  appropriate  vehicle,  namely,  powdered  sugar  of 
milk.  The  acids  used  at  the  factory— lactic  and  hydrochloric — 
are  the  best  to  be  met  with,  and  are  perfectly  combined  to  form 
a  permanent  preparation  ;  the  milk  sugar  is  absolutely  pure  ; 
the  powder  known  as  "diastase,"  or  starch-digesting  (tread, 
potaio,  and  pastry-digesting)  material,  as  well  as  the  ''  pan- 
creatin,"  or  fat-digesting  ingredient,  are  as  good  as  any  I  can 
prepare,  while  the  pepsin  is  much  superior  to  that  ordinarily 
used  in  medicine.  Indeed,  as  regards  this  chief  ingredient,-;- 
pepsin — I  have  only  met  with  one  European  or  American  speci- 
men equal  to  that  made  and  used  by  the  Manufacturer  of 
Lactopeptine.  A  perfectly  parallel  series  of  experiments  shov,  ^d 
that  any  given  weight  of  acidified  pepsin  alone  at  first  acts 
somewhat  more  rapidly  than  Lactopeptine  containing  the  same  weight  of  the  same  pepsin  Sooner  or  later, 
however,  the  action  of  the  Lactopeptine  overtakes  and  outstrips  that  of  pepsin  alone-due,  no  doubt,  to  the  meat- 
digesting,  as  well  as  fat-digesting,  power  of  the  pancreatin  contained  in  the  Lactopeptine.  My  conclusion  is 
that  Lactopeptine  is  a  most  valuable  digesting  agent,  and  superior  to  pepsin  alone.  JOHN  Al ..  t  lJ;.i-U. 

(Jne  of  the  chief  features  of  LACTOPEPTINE  (and  the  one  vhich  must  gain  it  a  preference  over  all 

digestive  preparations)  is,  that  it  preciselv  represents  in  composition  the  natural  digestive  juices  ot  thestomacH, 

pancreas,  and  salivary  glands,  and  wiU'  therefore  readily  Uissolve  aU  foods  necessary  to  the  recuperauon  ol  Uie 

human  organism.  ....  r         _i. 

Doge.— ONE>THIRD  that  of  cheap  substitutes,  and  giving  results  not  within  the  compass  01  any  otner 

r  Prices  of  Lactopeptine:— 1  oz.,  48.  6d.;  4  or.,  148.;  8  oz.,  278. 

Unstamped,  for  Dispensing  Only-Quarter  Pound  (4  oz.),  128.;  Half-pound  (8  oz.),  248. 
Lactopeptine  is  prepared  solely  by  JOHN  M.  RICHARDS, 
•    a*te  <5Teat  Russell  Street)  46  HolboPii  Viaduct,  London,  E.G. 


LiCTOPEPTiKB  contains  Ihe 
five  active  agents  of  diges- 
tion, coml'ined  in  the  same 
prop'  irtion  %» tliey  exist  in  the 
bumaii  stomach,  and  will  di- 
gcB!  food  in  a  manner  identi- 
cal to  that  obtained  unJei 
the  influence  of  the  natural 
gaetri''  joice. 

LiicruPKPTiNE  will  be  found 
far  superior  to  all  other  renje- 
dies  ill  IndiKestion,  Dyspep- 
sia, and  kindred  diseases. 

AU  ,  particidarly  indicated 
in  Anemia  General  Debility. 
Chroni.-  Diarrhoea,  Constipii- 
tio.i.  Headache,  Vomitiug 
and  Nausea  in  Pregnancy, 
and  impoverished  conditiuu 
of  the  blood . 

PRICE,    4/6. 

PREPARED  SOLELT   Bt 

JOHN   M.    RICHARDS, 

92  &  98,  GT.  BusaKLi.  St., 
LONDON. 


j  lnon 


A.  SA-i»**e  p»mpblet  and  Sample  ol  lAClopeptmb  sent  to  the  Medical  Profession,  on  request. 


Miscellaneous  Ailvertlsem'nts. 


CLUB  ALE.      CLUB  SODA.    CLUB  LEMONADE. 


NassauWorks 

Dublin^ 


WoodstockS'!"  Oxford  ST 


Belfast.     'London- 


Only  Makers  of  Sparkling  "  IVIOISTTSEI^RAT," 

The  Drink  for  the  Gouty  and  Rheumatic. 


Bullock's  PepsinaPorci. 


DOSE- 
2  to  4  grains 


Since  the  introduction  by  Dr.  Lionel  Beale  of   PEPSINA   PORCI, 
Mr.  Bullock  has  devoted  special  attention  to  its  manufacture. 


DOSE- 
1  to  2  drms. 


Bullock's  Acid  Glycerine  of  Pepsine. 

Possesses  at  least  three  times  the  digestive  power  of  (and  in  most  cases  considci'ahJy  more 
than)  any  other  preparation  of  Pepsine  and  Glycerine,  or  fluid  for  m  of  Pepsine  whatever. 

May  be  prescribed  with  most  substances  compatible  with  Acids. 
In  4  oz.,  8  oz.,  and  16  oz.  Bottles,  and  in  Bulk. 
The  published  experiments  of  G.  F.  Dowdeswell,  Esq.,  M.A.,'Jant.ab.,  F.C..S., 
F.L.S.,  &c.,  Dr.  Pavy,  Professor  TusoN,  the  late  Professor  Uabrod,  and  others, 
conclusively  demonstrate  the  marked  superiority  of  Bollock's  Pepsina  Porci  and 
Acid  Glycerine  of  Pepsine  over  every  other  Pepsine,  or  preparation  of  Pepsine — 
English,  French,  German,  or  American. 

* ^*  In  prescribing  either  of  the  above  preparations,  it  is  suggested  to  insert  in 
parentheses,  as  follows  (BUIilillCH.). 


cr.  L.  btjlXjOCk:  &c  co., 

3  Hanover-street,  Hanover-square,  London,  W. 


28 


Dublin  Journal  of  Medical  Science.t 


Leveson  &  Son's  Invalid  Furniture. 


READING    STAND, 

Brass  Column  and  Bronzed  Stand. 
PoliBhed  Walnut  Desk  -        -        £110 

Circular  Tube        .        -        -        -  0    7    6 

Brass  Lamp  -        -        -        -  0  10    6 


BED    TABLE. 

This  can  also  be  used,  as  shown  aboTe,  as  a 

Reading  or  Writing  Desk. 
Birch  polished  any  colour  -        £,2    5    O 

Walnut,  Mahogany,  or  Oak        -  3    3    O 


CARRYING    CHAIR. 

This  light  Carrjing  Chair  is  made  entirely  of 

Cane  snd  Malacca,  vrith  Bamboo  Handles, 

and  is  very  comfortable. 

Prices       -       -       21/-,  25/-,  35/-,  and  42/- 


BED    REST, 

From  12/6-  to  21/- 


Spinal  Board,  £1,  £1  10s.;  and  £1  15s.    \ 
Spinal  Carriages  from  8  to  20  Guineas.      ] 


Full  particulars  on 
application 


AG-ENTS    FOR    IREIjAMD 


FAKNIISI    .St    COMP-AKY, 

4X    GRAFTON     STRSSrr,    J^UBUIN^. 


Misfiellaneons  A  dvertinempnti^. 


20 


Leveson  (6  Son's  Invalid  Furniture. 


ILKLEY    COUCH. 

This  Couch  can  be  adjusted  to  any  required  position.     Price  fiom  2  to  10  O-uineas. 


MERLngr  chair. 

Made  of  solid  wood,  Oak  or  Mahogany,  from  4i  to  17  Guineas. 


INVALID'S    CARRIAGE,  from  £8 


WICKER  BATH-CHAIRS,  from  »  to  S  GUINEAS. 

LEG  RESTS,  INVALID  WATER  BEDS  and  CUSHIONS,  AIR  CUSHIONS  CRUTCHES 

and  every  description  of  Surgical  and  Medical  Appliances  for  Invalids. 


AGENTS    FOR    IRELAND 


41    GRAFTON    STREET,    DUBLIN. 
A  Complete  Cataloerue.sent  free  on  application. 


80  Dublin  Journal  of  Medical  Science. 

FANNIN  &  CO.  PATENT  TRUSi 


Price:  SINGLE,  £1  Is.;  DOUBLE,  £1  lis.  6d. 

The  only  Trass  ever  invented  on  correct  Surgical  and  Anatomical  principles  for 
the  relief  and  cure  of  Hernia. 


TO  BE  HAD  ONLY  FROM  THE  MAKERS, 

aurgtcal  tttsittttmrttt  ittanufactutejrsf, 
4X    GRAFTON^     STREET,    I^UBX^IM^. 

Registered  Telegraph  Address—"  FANmN,  DUBLIN." 

OXYGEN    INHALATION. 


Apparatus  for  the  inhalation  of  oxygen  gas,  as  suggested  by  Dr.  FoT. 


Price  lOs.  6cl.,  post  free. 


Descriptive  pamphlet  sent  on  application. 


FANNIN   &   COMPANY, 

Snrgical  Instrumemt  Makers,  Medical  Booksellers,  and  Pablishers, 

41     GRAFTON-STREET,     DUBLIN. 

[Tdegvam  Addreta — ''Fannin,  Dublin."] 


Miscellaneous  Advertisements.  81 


PRICE    OF   THE   APPARATUS 

FOR  THE 

INHALATION    OF    OXYGEN    GAS, 

AND 

Particulars  respecting  the  supply  of  the  Gas. 


The  Price  of  the  Apparatus  is  10/6. 

The  Oxygen  Gas  is  supplied  in  cylinders  containing  10,  20,  and 
40  cubic  feet,  at  the  rate  of  4(i.  and  bd.  per  cubic  foot,  according 
to  the  quantity  required.  For  cases  in  the  country,  where  a 
supply  cannot  be  obtained  at  a  moment's  notice,  Fannin  &  Co. 
recommend  that  the  larger  cylinders  should  be  ordered  in  the  first 
instance.  These  cylinders  are  kept  in  stock,  ready  for  immediate 
despatch  on  receipt  of  a  letter  or  telegram. 

Rate  of  Hirage  of  Cylinders. — Hirage  is  charged  at  the  rate 
of  %d.  per  week  for  the  smaller  sizes,  the  larger  sizes  in  propor- 
tion.    The  first  six  days  are  allowed  free. 
The  cylinders  can  be  purchased  if  desired. 

Empty  Cylinders. — It  is  requested  that  they  should  be  returned  at 
once. 

CAUTION. — No  oil  or  grease  must  on  any  account  be  used  for  the 
screws  or  fittings  of  the  cylinders. 


FANNIN      &      C0M:I>ANY, 

^urgiral  Instrument  ^abra, 

MEDICAL     BOOKSELLERS    AND     PUBLISHERS, 

41    GRAFTON     STREET,    DUBLIN. 


Tele^rraphic  Ad iress— "FANNIN,  DUBLIN. 


32  Ifuhlin  Journal  of  Medical  Science. 

DR.  HEUSTON'S    FOBCEPS 

FOR    THB 

REMOVAL  OF  STRUMOUS  GLANDS,  *c. 

Price   lOs.   6<i. 


"  Having  experienced  considerable  difficulty  in  the  removal 
of  strumous  glands,  owing  to  their  friable  character,  when 
caught  with  the  ordinary  clip  forceps,  I  had  this  instrument 
(as  shown)  made  by  Messrs.  Fannin  &  Co.,  and  find  it 
most  useful  for  the  purpose.  The  blades  coming  in  contact 
only  at  the  apex,  the  gland  is  received  within  the  fenestrated 
portion,  and  thus  is  not  broken.  The  instrument  will  ai&«> 
be  found  useful  in  the  removal  of  any  morbid  growth. 

"FKANCIS  T.  HEUSTON,  M.D..  F.E.C.S.L, 

Surgeon,  Adelaide  Hospital,  Dublin ; 
Professor  of  Anatomy,  Royal  College  of  Surgeons,  Ireland 
Consulting  Surgeon,  Coombe  Hospital,  Dublin." 

Decbmber,  1 391. 


l^liscellaneoiis  A  dvertisemenU 


34 


Duhlhi  Journal  of  Medical  Science. 


FANNIN    &   COMPANY, 


VAGINAL  SPECULUM. 

As  used  at  the  Rotunda  Hospital,  Dublin. 

Price  20S. 


DOUCHING  CUKETTE. 

As  used  at  the  Rotunda  Hospital,  DubUn. 

Price  gs. 


UTERINE  CANULA  (for  Cervical  Medication). 

As  used  at  theRotunda  Hospital,  Dublin. 

Price  8s.  6d. 

All  these  Instruments  are  made  entirely  of  metal,  to  enable  them  to  be  boiled  and 

antisepticised. 


UTERINE  DOUCHE. 

As  used  at  the  Rotunda  Hospital,  Dublin. 

Price  7s.  6d. 
FEMALE  GLASS  CATHETER,  4d.    GLASS  UTERINE  DOUCHE  TUBE,  4d. 


MiscellaneouK  A  dvertisements. 


35 


THE  ROBERTS  &  ALLISON 

Physicians'  and  Surgeons'  Operating  Chair. 

This  Chair  has  been  specially  constructed  to  meet  the  wants  and  requirements  of  the 
Profession.  It  is  simply  constructed,  with  perfect  adjustment,  strength,  and  convenience, 
without  those  complications  noticeable  in  other  chairs.  It  can  be  easily  moved  to  its 
different  positions  by  the  operator  without  changiEg  his  position. 


Normal  Position. 

Can  be  also  iised  as  an  Ordinary 
Office  Chair. 


Lateral  or  Sinus  Position. 

This  position  is  imjiortant  to  gjTiaecologists,  and 
in  treatment  of  rectal  diseases,  with  side  ti.ble  for 
instruments. 


Horizontal  Position  For  Ansesthesia  Narcosis. 

This  position  is  very  important  in  cases  of  hieniorr- 
hage  or  svispended  animation,  and  can  be  obtained 
instantly.  The  patient  can  be  rocked  up  8nd  down 
by  pressing  the  lever. 

It  can  also  be  placed  in  the  dorsal  and  genito- urinary  positions.     This  Chair  has  given 
the  greatest  satisfaction  wherever  used,  and  is  suitable  for  private  and  hospital  practice. 

Price  of  aboT'e,  ^13. 

Any  further  information  and  particulars  can  be  obtained  from 

FANNIN    ANO     C01VII>ANY, 

Jbolr  Egpntis  for  Srclanlr, 
41    GRAFTON-STREET,    DUBLIN. 


^fi  Dublin  Journal  of  Medicdl  Science. 

LORIMER'S  COCA  WINE. 

Prepared  from  COCA.  LEAVES  (Erythroxylon  Coca). 
In  Bottles,  36/-  per  dozen. 

LHlfS 

HYPOPHOSPHITES. 

"SYRUP  HYPOPHOSPH.  CO.  (LORIMER)." 

Among  the  principal  merits  of  this  preparation  may  be  enumerated : — 

1st. — It  is  not  a  quack  preparation  or  secret  nostrum;  the  formula 
is  printed  on  every  label,  and  the  price  is  moderate. 

2nd. — The  formula  is  original,  founded  upon  scientific  principles, 
and  has  stood  the  test  of  practical  experience.  There  is  no  other 
preparation  of  the  hypophosphites  which  contains  so  large  a  proportion 
(about  six  grains  to  the  fluid  drachm)  of  the  salts  employed. 

3rcl. — All  its  constituents  are  in  perfect  and  permanent  solution, 
the  last  dose  being  identical,  under  aU  circumstances,  with  the  first. 
There  is  consequently  no  possibility  of  danger  from  the  precipitation  of 
strychnine,  as  is  the  case  with  preparations  that  require  shaking  to  dis- 
tribute the  dose. 

4th. — The  formula  being  stated  on  every  label,  the  physician  is  enabled 
to  vary  the  dose  according  to  the  requirements  or  idiosyncrasies  of  the 
individual  case. 

5th. — It  is  pleasant  to  take,  and  can  readily  be  prescribed  for  children. 

6th. — It  is  neutral,  or  very  slightly  alkaline,  and  can  therefore  be 
taken  without  ill  effect  by  persons  afflicted  with  sensitive  stomachs, 
which  would  probably  reject  acid  or  strongly  alkaline  preparations. 


IODISED  Olli 

(Oleum  lodi). 

FOR  OUTWARD  APPLICATION  ONLY. 

ADVANTAGES. — Is  readily  absorbed.     Does  not  stain  the  skin.     May  be 

applied  to  the  most  delicate  skin  without  irritation. 

In  16-oz.  Bottles,  6/-  each. 

Price  List  of  Larimer's  Specialities  sent  on  application. 

LORIMER  &  CO.,  Britannia  Row,  LONDON,  N„ 

WHOLESALE  DBUGGISTS  AND  MANUFACTUHING  CHEMISTS. 


Miscellaneous  Advertisements.  37 

CLINICAL    SLATE, 

Designed  by  HENRY  DAVY,  M.B.,  M.-Ch.,  Univ.  Dub.,  &c. 
FOR  RECORDING  PARTICULARS  OF  PRIVATE  AND  HOSPITAL  CASES. 


"  A  simple  invention,  dpsigtied  to  facilitate  the  working  together  of  medical  attendant  and  nurse. 
.  .  .  The  slate  will  undouhtedly  be  convenient  in  serious  cases,  wliere  a  careful  record  of  the 
patient'scnndition  from  hour  to  hour  is  desirable." — British  Medical  Journal. 

"  A  clinical  slate,  submitted  to  us  by  Messrs.  Faskin  <fc  Co.,  41  Graf  ton-street .  Dublin,  is  practi- 
cally fl  permanent  chan,  on  which  can  be  recorded  treatment  and  general  directions  of  '  cases,  <tec.'  ; 
its  advantage  being  that  it  can  be  used,  by  merely  sponging  out  the  entries,  for  any  length  of  time,  and 
for  any  number  of  patients."     The  Nursing  Record. 

"Messrs  Fannin  &,  Co.,  Dublin,  have  sent  us  a  very  neat  clinical  slate  for  the  use  of  nurses  in 
private  houses.  To  systematise  and  arrange  their  inforniation  for  the  doctor's  vibit,  it  is  divided  by 
vertical  lines  so  as  to  give  a  column  for  each  hour  of  the  day,  and  by  horizontal  lines  for  each  detail, 
such  as  pulse,  temperature,  bowels,  urine,  food,  stimulants,  and  medicine.  It  can  he  used  to  write 
orders  for  the  nurse  as  well  as  a  daily  journal  for  her,  most  easily  kept,  with  the  minimum  of  trouble."  — 
Edinburgh  Medical  Journal. 

"  The  slate  is  carefully  rulcl  in  spaces  for  the  noting  of  the  temperatare,  pulse,  diet,  Ac,  of  the 
patient  during  the  twenty-four  hours,  and  can  then  be  clean 'd  and  used  again."— TAu  Hospital. 

Messrs.  FANNIN  &  CO.,  41  GRAFTQN-STREET,  DUBLIN. 

DIABETES, 

Gluten  Bread  and  Biscuits, 

Recommended  by  Dr.  PAVT. 

Every  Variety  of  Gluten,  Almond  Bran,  Chocolate  Cocoanut  for 
Diabetic  Dietary. 

SEND  FOR   PRICE   LISTS. 

BONTHRON    &    CO.,    106    Regent-street,   LONDON. 


DR.  HEUSTON'S  EMPYEMA  TUBE, 


Pi-iee  3/-. 

'lKJ^l<TUFj^CTTT:RTi:iJD    BY 

FANNIN  &  CO.,  41  Grafton-street,  Dublin. 


38 


Dublin  Journal  of  Medical  Science, 


THE    ORIGINAL    RAW    FOOD    EXTRACT. 

(Prpsoribod  by  the  Medical  Profession  since  1878.) 


THE    VITAL    PRINCIPLES    OF    BEEF    CONCENTRATED. 

CONTAINING  20  PER   CENT.  OF  C0A6ULABLE   ALBUMEN. 


Its  ready  assimilability,  its  marked  nutritive  quality,  its  stimu- 
'lating  power,  and  restorative  force,  make  BOVININE  a  most 
valuable  aid  in  all  treatment  where  a  true  nutrient  is  indicated. 


SAMPLES  free  to  the  Medical  Profession  on  application  to  the  Company. 

PREPARED  ONLY  BY 

THE  BOVININE  COMPANY,  32  SNOW  HILL  LONDON,  E.G. 

Sold  hy  Chemists.     In  Bottles,  1 2  oz.,  4s.  6c?. ;  6  oz.,  2s.  9d. 

IDR.  I>.  C.  SIVIYLY'S  FOI^CEI>S, 

For  the  Removal  of  Enlarged  Follicles  from  the  Pharynx. 


Plaice  lOs. 

The  treatment  of  follicular  pharyngitis  consists  mainly  in  destroying  the  enlarged 
glandules  by  caustic  pastes  or  the  galvano-cautery.  An  objection  to  the  former 
method  is  the  difficulty  of  limiting  the  caustic  action  to  the  diseased  part.  The 
galvano-cautery  is  unwieldy  and  expensive,  and  not  always  at  hand  ;  moreover,  its 
use  is  not  unattended  with  some  dansrer,  as  the  wire  has  baen  known  to  fuse,  and 
loss  of  voice  result.  A  cicatrix  sometimes  remains  after  the  application  of  the 
cautery,  which  is  very  irritating  to  the  patient.  The  spoon- shaped  forceps  are  free 
from  these  drawbacks  and  will  be  found  especially  suitable  for  the  earlier  cases.  A 
20  per  cent,  solution  of  cocaine  having  been  applied,  the  forceps  are  introduced,  the 
follicle  seized  vertically  and  twisted  oflE.  The  operation  is  simple,  effectual,  and 
painless.  

MANUFACTURED    BY— 

FANNIH    &    COMPANY, 

glanufattunrs  of  Surgical  |nstru mmts  ant)  g^pliartas, 
41    GRAFTON-STREET,    DUBLIN. 


GOLD  MEDAL,  International  Health  Exhibition,  Lonrlon,  ISSi. 

First  Order  of  Merit  &  Medal  (Highest  Award),  Adelaide,  1^87 

HIGHEST  A'WARD,Medical  &  Sanitary  Exhibition,  London,  1882 

First  Order  of  Merit  and  Medal,  Melbourne,  1888. 


BENGER'S    FOOD 

FOR  INFANTS,  CHILDREN,  AND  INVALIDS. 

This  delicious  and  highly  nutritive  Food  was  awarded  the  Gold  Medal  at  the 
International  Health  Exhibition,  London,  and  has  since  received  a  High  Award 
at  every  Exhibition  at  which  it  has  been  'hown. 

BENGER'S  FOOD  is  well  known  to  leading  medical  men,  and  is  recommended  by 
them. 

The  following  extracts  from  the  Medical  Journals  sufficiently  indicate  its  high 
character,  and  the  estimation  in  which  it  is  held  alike  by  the  Medical  Profession  and 
by  the  Public  :— 

The  LANCET  of  March  25th,  1882,  says:— 

"Would  be  assimilated  with  great  ease." 

The  BRITISH  MEDICAL  JOURNAL,  Aug.  25th,  1883,  says:  — 

"  Bi-nger's  Food  has  by  ith  excellence  established  a  reputation  of  its  own." 

The  ILLUSTRATED  MEDICAL  NEWS,  Dec.  22,  1888,  says:— 

"  Benger's  Food  is  a  preparation  devised  on  original  lines,  and  which  we  can  speak 
of  in  the  highest  terms.  .  .  .  Infants  do  remarkably  well  on  it,  and  it  is  most 
suitable  for  many  conditions  in  adults  and  old  people.  Amongst  other  things,  we  may 
mention  that  this  food  has  been  found  extremely  useful  in  the  Summer  Diarrhoea  met 
with  in  some  of  our  Colonies,  where  the  distaste  for  food  and  difficulty  of  digestion  are 
very  marked.     Tliere  is  certainly  a  great  future  before  it." 

The  LONDON  MEDICAL  RECORD,  March  15,  1882,  says:  — 

"  It  is  palatable  and  excellent  in  every,  way.  It  is  taken  readily  both  by  adults  and 
children.  We  have  given  it  in  very  many  cases  with  the  most  marked  benefit,  patients 
frequently  retaining  it  after  every  other  food  has  been  rejected.  For  children  who 
throw  up  their  food  in  curdled  masses  it  is  invaluable." 

The  JOURNAL  DE  MEDICINE  DE  PARIS,  March  17,  1889,  says:— 

"  C'est  un  exomple  henreux  de  I'application  des  donn^es  de  la  science  k  la  pratique, 
et  nous  ne  doutons  pas  que  ce  produit  ne  jouisse  bient6t  en  France  de  la  grande  vogue 
qu'il  s'est  l^gitimement  acquise  en  Angleterre." 

The  HEALTH  JOURNAL,  November,  1883,  says:  — 

"We  direct  especial  attention  to  this  article,  because  it  is  a  good  illustration  of  the 
practical  application  of  scientific  knowledge  to  one  of  the  every  day  requirements  of 
mankind." 

From  an  Eminent  Surgeon. 

"  After  a  lengthened  experience  of  Foods,  both  at  home  and  in  India,  I  consider 
"Benger's  Food  '  incomparably  superior  to  any  I  have  ever  prescribed." 

A  Medical  Man  writes: — 

"  This  particular  food  is  the  only  one  I  have  been  able  to  take  constantly  and  with 
advantage.     1  have  prescribed  it  for  others  with  the  best  results." 

BENGER'S  FOOD  ia  sold  in  Tins  at  Is.  6d.,  28.  6d.,  Ss.,  &  lOs.  each,  by  Chemists,  &c., 

everywhere  ;  and  may  be  obtained  through  all  the  leading  Wholesale 

Houses,  or  of  tlio  Manufacturers — 

F.  B.  BENGER  &  CO.,  Limited, 

OTTER   WORKS,   MANCHESTER. 


40 


Dublin  Journal  of  MeJical  Science. 


GODFREY'S  CHLORIDE  OF  AMMONIUM 

INHALER. 

LOSS  OF  VOICE, 

THROAT  AND   EAR 

AFFECTIONS, 

HAY   ASTHMA. 

Price,  retail,  7s.  6d. 

Profession,  5s. ; 
Post,  6d.  extra. 


Prospectus  free  by  Post. 

Sole  Makers- GODFREY  &  COOKE,  30  Condpit  Street,  Bond  Street.  W. 

NERVOUS  EXHAUSTION. 

PULVERMACHER'S  WORLD-FAMED  GALVAISTIC 
BELTS,  for  the  cure  of  NERVOUS  Diseases,  have  received 
Testimonials  from  Three  Physicians  to  Her  Majesty  the  Queen,  and 
over  Forty  Members  of  the  Royal  College  of  Physicians  of  London. 

The  distressing  symptoms  of  NERVOUS  EXHAUSTION,  loss 
of  MUSCULAR  POWER,  RHEUMATISM,  SCIATICA,  PARALYSIS, 
EPILEP&Y,  &c.,  are  speedily  removed  by  means  of  PULVER- 
MACHER'S WORLD-FAMED  GALVANIC  BELTS,  which  convey 
the  electric  current  direct  to  the  affected  parts,  gradually  stimu- 
lating and  strengthening  all  the  nerves  and  muscles,  and  speedily 
arresting  all  symptoms  of  premature  waste  and  decay. 

Dr.  Vines,  Fellow  of  the  Royal  CoUejo'e  of  Physicians,  writes,  19th  September, 
1885  : — "Having  used  Mr.  Pdlvekmacher's  Belts  for  many  years,  in  the  course  of 
medical  practice,  I  am  in  a  position  to  speak  of  their  great  value  as  a  curative  agent 
in  cases  of  nervous  disease  or  functional  malady  where  Electricity  is  likely  to  be 
serviceable.     I  am  entirely  convinced  of  their  efficacy." 

Dr.  H.  A.  Allbott,  M.R.C.P.,  24  Park  Square,  Leeds,  writes,  October,  1888:  — 
"  I  always  recormnend  with  confidence  Mr.  Pdlvekmacher's  Belts.  Ladies  recover- 
ing from  illness  incidental  to  their  sex  will  find  these  Belts  of  vast  assistance  in 
restoring  lost  nerve  power." 

Sir  Charles  Locock,  Bart.,  M.D.,  says — "  Pdlvermaoher's  Belts  are  very 
eflfective  in  neuralgia  and  rheumatic  affections,  and  I  have  prescribed  them  large[y  in 
my  practice  for  other  similar  maladies,  paralysis,"  &c. 

For  full  Price  List  and  Particulars  see  new  Pamphlet — "Galvanism:  Nature's 
Chief  Restorer  of  Impaired  Vital  Energy."     Post  free  from 

PULVERMACHER'S  Galvanic  Establishment, 

104  R-egfent-sti'eet,  Loiitloii,  "W. 

ESTABLISHED  OVER  FORTY  YEARS 


FANlSriN"    &    CO.,   SOLE  AGENTS   FOR   IRELAND, 
41    GRAFTON-STREET,    DUBLIN. 


A  New  Form  of  Vaginal  Irrigating  Tube. 

By     ALEXANDER     DUKE,     F.  R.  C.  S., 

Obstetric  Physician  to  Steevens"  HoBi>ital, 

Price  lOs.  Ocl. 


Extract  from  "Medical  Press," 
April  20,  1892. 
It  is  almost  an  impossibility 
■with  the  ordinary  means  at  our 
disposal  to  wash  out  the  vagina 
while  the  patient  is  in  the  recum- 
bent position  without  wettinw 
either  the  bed  or  couch  on  which 
she  lies. 

It  will  be  generally  admitted 
that  the  principal  value  of  a 
vaginal  lavement  will  be  lost  if 
not  administered  while  in  the 
recumbent  position,  so  that  I  ven- 
ture to  hope  that  the  appliance 
illustrated  will  be  found  in  every- 
day practice  to  supply  a  want 
both  to  obstetrician,  gyntecolo- 
gist,  and  monthly  nurse.  By  the 
use  of  this  simple  form  of  irriga- 
tor tube  all  wetting  of  the  bed 
and  patient  will  be  avoided, 
whether  used  by  the  patient  her- 
self or  employed  by  her  attend- 
ant. The  usual  preliminary  alter- 
ation of  the  patient's  position, 
bringing  hips  to  edge  of  bed, 
waterproof  sheet,  &c.,  can  all  be 
dispensed  with. 

The  appliance  consists  of  an 
ordinary  funnel  through  which  a 
vulcanite  or  glass  tube  passes, 
and  which  can  be  shortened  or 
lengthened  at  will.  This  tube 
with  apex  of  funnel  is  to  be  intro- 
duced into  vagina  (the  former 
having  been  previously  filled  with 
water) ,  both  are  now  pressed  firm- 
ly into  the  passage  and  held  in 
close  contact  with  the  vulva.  'I'lie 
lavement  is  then  to  be  adminis- 
tered in  the  usual  way,  either  by 
syringe  or  douche,  and  if  the  funnel  be  properly  held,  the  return  current  cannot 
possibly  escape  except  round  the  tube  into  the  apex  of  the  funnel  in  vagina  ;  and  so  finds 
its  ■^ay  out  of  exit  pipe  on  side  of  same,  to  which  tubing  may  be  attached  leading 
to  Tessel  underneath  the  bed  if  desired. 

Having  experienced  the  comfort  and  saving  of  botli  time  and  temper  by  the  use 
of  t]^  appliance  described,  I  have  no  he»-itation  in  recommending  its  adoption  as  a 
vast'  improvement  on  any  form  of  vHginal  tube  I  have  ever  heard  of,  or  seen 
pictured  in  any  of  the  various  surgical  instrument  catalogues  CNtant. 

MANUFACTURED    BY 

^urcjical  i^ttjoit  runt  rut  Maftri% 

-4=1    OKAirTOJX-tesTKlClilT,    DUBLIN. 


Apollinaris 

'['EE  1J21ES  writes  :— 

'APOLLINARIS      WATER      is     as    familiar    in 
millions  of  mouths  as  any  household  word." 

"Those  who  who  are  in  health  hope  to  remain  well  ^  ^ 
makinsf  APOLLINARIS  their  habitual  beveraofe." 

■  Invalids  are  recommended  to  drink  it  in  order  ^r,  ■• 
rid  of  their  ailments." 

The  water  is  cheap  as  well  as  good." 

The  demand  for  it  is  great  and  increasing." 

The    popularity    of   APOLLINARIS  WATER 

chiefly  due  to  its  irreproachable  character." 

The  bottled  watkr  is  not  only  as  pure  but  as  gasec 
as  the  same  water  is  far  down  in    the    rock,  through 
in  which  it  ascends." 

The  Drinker  is  certain  of  obtaining  it  in  its  purl^ly 
natural  state." 

The  pleasant  taste  is  due  to  its  chemical  constitften 
uid  for  the  same  reason  the^ater  itself  is  more  wholesui 
tlmn  ,i!iy  aerated  one  which  art  can  Rupply  " 

Apollinaris, 

"THE  QUEEN  OF  TABLE  WATERS." 
;  i  '     \P0LL1NARIS  CO.,  Ltd.,  19  Regent-st.,  London,